EXCHANGES_CVSC Template Legacy SP eff 01/01/2015
Drug Name
Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
amphetamine-dextroamphetamine cap sr
24hr 5 mg
amphetamine-dextroamphetamine cap sr
24hr 10 mg
amphetamine-dextroamphetamine cap sr
24hr 15 mg
amphetamine-dextroamphetamine cap sr
24hr 20 mg
amphetamine-dextroamphetamine cap sr
24hr 25 mg
amphetamine-dextroamphetamine cap sr
24hr 30 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
amphetamine-dextroamphetamine tab 10
mg
amphetamine-dextroamphetamine tab
12.5 mg
amphetamine-dextroamphetamine tab 15
mg
amphetamine-dextroamphetamine tab 20
mg
amphetamine-dextroamphetamine tab 30
mg
dextroamphetamine sulfate cap sr 24hr 5
mg
dextroamphetamine sulfate cap sr 24hr 10
mg
dextroamphetamine sulfate cap sr 24hr 15
mg
dextroamphetamine sulfate tab 5 mg
dextroamphetamine sulfate tab 10 mg
methamphetamine hcl tab 5 mg
VYVANSE CAP 20MG
1
QL (90 caps / 25 days)
1
QL (90 caps / 25 days)
1
QL (30 caps / 25 days)
1
QL (30 caps / 25 days)
1
QL (30 caps / 25 days)
1
QL (30 caps / 25 days)
1
QL (90 tabs / 25 days)
1
QL (90 tabs / 25 days)
1
QL (90 tabs / 25 days)
1
QL (90 tabs / 25 days)
1
QL (60 tabs / 25 days)
1
QL (60 tabs / 25 days)
1
QL (30 tabs / 25 days)
1
QL (120 caps / 25 days)
1
QL (120 caps / 25 days)
1
QL (60 caps / 25 days)
1
1
1
3
VYVANSE CAP 30MG
3
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (150 tabs / 25 days)
QL (60 caps / 25 days),
PA; PA applies for
members age 19 and
older
QL (60 caps / 25 days),
PA; PA applies for
members age 19 and
older
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
1
Drug Name
VYVANSE CAP 40MG
Drug Tier Requirements/Limits
3
QL (30 caps / 25 days),
PA; PA applies for
members age 19 and
older
3
QL (30 caps / 25 days),
PA; PA applies for
members age 19 and
older
3
QL (30 caps / 25 days),
PA; PA applies for
members age 19 and
older
3
QL (30 caps / 25 days),
PA; PA applies for
members age 19 and
older
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
zenzedi tab 2.5mg
zenzedi tab 7.5mg
Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
INTUNIV TAB 1MG
INTUNIV TAB 2MG
INTUNIV TAB 3MG
INTUNIV TAB 4MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRATTERA CAP 100MG
3
3
3
3
2
2
2
2
2
2
2
ST; PA**
ST; PA**
ST; PA**
ST; PA**
QL (120 caps / 25 days)
QL (120 caps / 25 days)
QL (120 caps / 25 days)
QL (60 caps / 25 days)
QL (30 caps / 25 days)
QL (30 caps / 25 days)
QL (30 caps / 25 days)
DAYTRANA DIS 10MG/9HR
3
DAYTRANA DIS 15MG/9HR
3
DAYTRANA DIS 20MG/9HR
3
DAYTRANA DIS 30MG/9HR
3
dexmethylphenidate hcl cap sr 24 hr 15
mg
dexmethylphenidate hcl cap sr 24 hr 30
mg
1
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
days)
QL (60
1
QL (30 caps / 25 days)
Stimulants - Misc.
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
patches / 25
patches / 25
patches / 25
patches / 25
caps / 25 days)
PA** - PA Applies if
2
Drug Name
dexmethylphenidate hcl
mg
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
FOCALIN XR CAP 5MG
FOCALIN XR CAP 10MG
FOCALIN XR CAP 20MG
FOCALIN XR CAP 25MG
FOCALIN XR CAP 35MG
metadate tab 20mg er
METHYLIN CHW 2.5MG
cap sr 24 hr 40
tab 2.5 mg
tab 5 mg
tab 10 mg
Drug Tier Requirements/Limits
1
QL (30 caps / 25 days)
1
1
1
3
3
3
3
3
1
3
METHYLIN CHW 5MG
3
METHYLIN CHW 10MG
3
methylin tab 5mg
methylin tab 10mg
methylin tab 10mg er
methylin tab 20mg
methylin tab 20mg er
methylphenidate hcl cap cr 10 mg
methylphenidate hcl cap cr 20 mg
methylphenidate hcl cap cr 30 mg
methylphenidate hcl cap cr 40 mg
methylphenidate hcl cap cr 50 mg
methylphenidate hcl cap cr 60 mg
methylphenidate hcl cap sr 24hr 20 mg
methylphenidate hcl cap sr 24hr 30 mg
methylphenidate hcl cap sr 24hr 40 mg
methylphenidate hcl soln 5 mg/5ml
methylphenidate hcl soln 10 mg/5ml
methylphenidate hcl tab 5 mg
methylphenidate hcl tab 10 mg
methylphenidate hcl tab 20 mg
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
methylphenidate hcl tab sa osm 18 mg
methylphenidate hcl tab sa osm 27 mg
methylphenidate hcl tab sa osm 36 mg
methylphenidate hcl tab sa osm 54 mg
modafinil tab 100 mg
modafinil tab 200 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (60 tabs / 25 days)
QL (60 caps / 25 days)
QL (60 caps / 25 days)
QL (60 caps / 25 days)
QL (30 caps / 25 days)
QL (30 caps / 25 days)
QL (90 tabs / 25 days)
QL (180 chew tabs / 25
days)
QL (180 chew tabs / 25
days)
QL (180 chew tabs / 25
days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL (90 caps / 25 days)
QL (90 caps / 25 days)
QL (90 caps / 25 days)
QL (90 caps / 25 days)
QL (90 caps / 25 days)
QL (90 caps / 25 days)
QL (60 caps / 25 days)
QL (60 caps / 25 days)
QL (30 caps / 25 days)
QL (1800 mL / 25 days)
QL (900 mL / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL (60 tabs / 25 days)
QL (60 tabs / 25 days)
QL (60 tabs / 25 days)
QL (30 tabs / 25 days)
PA
PA
PA** - PA Applies if
3
Drug Name
NUVIGIL TAB 50MG
NUVIGIL TAB 150MG
NUVIGIL TAB 200MG
NUVIGIL TAB 250MG
RITALIN LA CAP 10MG
Drug Tier Requirements/Limits
2
PA
2
PA
2
PA
2
PA
2
QL (60 caps / 25 days)
AMINOGLYCOSIDES
Aminoglycosides
amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1
amikacin sulfate inj 100 mg/2ml (50
1
mg/ml)
amikacin sulfate inj 500 mg/2ml (250
1
mg/ml)
GENTAM/NACL INJ 0.9MG/ML
3
GENTAM/NACL INJ 1.4MG/ML
3
gentamicin in saline inj 0.8 mg/ml
1
gentamicin in saline inj 1 mg/ml
1
gentamicin in saline inj 1.2 mg/ml
1
gentamicin in saline inj 1.6 mg/ml
1
gentamicin in saline inj 2 mg/ml
1
gentamicin sulfate inj 10 mg/ml
1
gentamicin sulfate inj 40 mg/ml
1
gentamicin sulfate iv soln 10 mg/ml
1
kanamycin sulfate inj 333 mg/ml
1
NEO-FRADIN SOL 125/5ML
3
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap 250 mg
1
streptomycin sulfate for inj 1 gm
1
TOBRA/NACL INJ 60/0.9
3
TOBRA/NACL INJ 80/0.9
3
tobramycin nebu soln 300 mg/5ml
4
tobramycin sulfate inj 1.2 gm/30ml (40
1
mg/ml)
tobramycin sulfate inj 2 gm/50ml (40
1
mg/ml)
tobramycin sulfate inj 10 mg/ml
1
tobramycin sulfate inj 80 mg/2ml (40
1
mg/ml)
PA
ANALGESICS - ANTI-INFLAMMATORY
Anti-TNF-alpha - Monoclonal Antibodies
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEN KIT CROHNS
SIMPONI ARIA SOL 50MG/4ML
SIMPONI INJ 50MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA, ST
PA, ST
PA** - PA Applies if
4
Drug Name
SIMPONI INJ 100MG/ML
Drug Tier Requirements/Limits
4
PA, ST
Antirheumatic - Enzyme Inhibitors
XELJANZ TAB 5MG
4
PA, ST
Antirheumatic Antimetabolites
RHEUMATREX TAB 2.5MG
3
Interleukin-1 Blockers
ARCALYST INJ 220MG
4
PA
Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET INJ
4
PA, ST
4
4
4
4
PA,
PA,
PA,
PA,
Interleukin-6 Receptor Inhibitors
ACTEMRA
ACTEMRA
ACTEMRA
ACTEMRA
INJ
INJ
INJ
INJ
80MG/4ML
162/0.9
200/10ML
400/20ML
ST
ST
ST
ST
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
CELEBREX CAP 50MG
CELEBREX CAP 100MG
CELEBREX CAP 200MG
CELEBREX CAP 400MG
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25
mg
diclofenac sodium tab delayed release 50
mg
diclofenac sodium tab delayed release 75
mg
diclofenac sodium tab sr 24hr 100 mg
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg
diclofenac w/ misoprostol tab delayed
release 75-0.2 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
etodolac tab sr 24hr 600 mg
fenoprofen calcium tab 600 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen sus 100/5ml
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
3
1
1
ST
ST
ST
ST
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC
PA** - PA Applies if
5
Drug Name
INDOCIN SUS 25MG/5ML
indomethacin cap 25 mg
indomethacin cap 50 mg
indomethacin cap cr 75 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketoprofen cap sr 24hr 200 mg
ketorolac tromethamine im inj 30 mg/ml
ketorolac tromethamine im inj 60 mg/2ml
(30 mg/ml)
ketorolac tromethamine inj 15 mg/ml
ketorolac tromethamine inj 30 mg/ml
ketorolac tromethamine inj 60 mg/2ml (30
mg/ml)
ketorolac tromethamine inj 300 mg/10ml
(30 mg/ml)
ketorolac tromethamine tab 10 mg
meclofenamate sodium cap 50 mg
meclofenamate sodium cap 100 mg
mefenamic acid cap 250 mg
meloxicam susp 7.5 mg/5ml
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
NALFON CAP 200MG
NALFON CAP 400MG
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
oxaprozin tab 600 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg
tolmetin sodium cap 400 mg
tolmetin sodium tab 200 mg
tolmetin sodium tab 600 mg
Drug Tier Requirements/Limits
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (20 tabs / 25 days)
ST
ST
Pyrimidine Synthesis Inhibitors
leflunomide tab 10 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
6
Drug Name
leflunomide tab 20 mg
Drug Tier Requirements/Limits
1
Selective Costimulation Modulators
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
4
4
PA, ST
PA, ST
Soluble Tumor Necrosis Factor Receptor Agents
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
4
4
4
PA
PA
PA
ANALGESICS - NonNarcotic
Analgesics-Sedatives
butalbital-acetaminophen-caffeine cap 50325-40 mg
butalbital-acetaminophen-caffeine tab 50325-40 mg
butalbital-aspirin-caffeine cap 50-325-40
mg
butalbital-aspirin-caffeine tab 50-325-40
mg
1
1
1
1
Salicylates
ADULT ASA TAB 81MG QM
0
aspirin chew tab 81 mg
0
aspirin low tab 81mg ec
0
ASPIRIN TAB 81 MG
0
aspirin tab 325 mg
0
aspirin tab delayed release 325 mg
0
diflunisal tab 500 mg
HALFPRIN TAB 162MG EC
1
0
QL (100
OTC
QL (100
OTC
QL (100
OTC
QL (100
OTC
QL (100
OTC
QL (100
OTC
tabs / 30 days);
tabs / 30 days);
tabs / 30 days);
tabs / 30 days);
tabs / 30 days);
tabs / 30 days);
QL (100 tabs / 30 days);
OTC
ANALGESICS - OPIOID
Opioid Agonists
ABSTRAL SUB 100MCG
3
ABSTRAL SUB 200MCG
3
ABSTRAL SUB 300MCG
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (120 Units per 25
days), PA
QL (120 Units per 25
days), PA
QL (120 Units per 25
days), PA
PA** - PA Applies if
7
Drug Name
ABSTRAL SUB 400MCG
ABSTRAL SUB 600MCG
ABSTRAL SUB 800MCG
astramorph inj 1mg/2ml
astramorph inj 2mg/2ml
CODEINE SULF SOL 30MG/5ML
codeine sulfate tab 15 mg
codeine sulfate tab 30 mg
codeine sulfate tab 60 mg
DILAUDID-HP INJ 250MG
EMBEDA CAP 30-1.2MG
EXALGO TAB 8MG
EXALGO TAB 12MG
EXALGO TAB 16MG
EXALGO TAB 32MG
fentanyl citrate lollipop 200 mcg
fentanyl citrate lollipop 400 mcg
fentanyl citrate lollipop 600 mcg
fentanyl citrate lollipop 800 mcg
fentanyl citrate lollipop 1200 mcg
fentanyl citrate lollipop 1600 mcg
fentanyl td patch 72hr 12 mcg/hr
fentanyl td patch 72hr 25 mcg/hr
fentanyl td patch 72hr 50 mcg/hr
fentanyl td patch 72hr 75 mcg/hr
fentanyl td patch 72hr 100 mcg/hr
FENTORA TAB 100MCG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
3
QL (120 Units per 25
days), PA
3
QL (120 Units per 25
days), PA
3
QL (120 Units per 25
days), PA
1
1
2
1
QL (45 tabs / 25 days)
1
QL (45 tabs / 25 days)
1
QL (45 tabs / 25 days)
3
3
QL (60 caps / 25 days)
3
QL (60 tabs / 25 days)
3
QL (60 tabs / 25 days)
3
QL (60 tabs / 25 days)
3
QL (60 tabs / 25 days)
1
QL (120 lozenges / 25
days), PA
1
QL (120 lozenges / 25
days), PA
1
QL (120 lozenges / 25
days), PA
1
QL (120 lozenges / 25
days), PA
1
QL (120 lozenges / 25
days), PA
1
QL (120 lozenges / 25
days), PA
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
3
QL (120 Units per 25
days), PA
ST - Step Therapy
PA** - PA Applies if
8
Drug Name
FENTORA TAB 200MCG
Drug Tier Requirements/Limits
3
QL (120 Units per 25
days), PA
FENTORA TAB 400MCG
3
QL (120 Units per 25
days), PA
FENTORA TAB 600MCG
3
QL (120 Units per 25
days), PA
FENTORA TAB 800MCG
3
QL (120 Units per 25
days), PA
HYDROMORPHON SUP 3MG
3
hydromorphone hcl liqd 1 mg/ml
1
QL (180 mL / 25 days)
hydromorphone hcl tab 2 mg
1
QL (180 tabs / 25 days)
hydromorphone hcl tab 4 mg
1
QL (180 tabs / 25 days)
hydromorphone hcl tab 8 mg
1
QL (180 tabs / 25 days)
KADIAN CAP 40MG CR
3
QL (60 caps / 25 days)
KADIAN CAP 70MG CR
3
QL (60 caps / 25 days)
KADIAN CAP 130MG CR
3
QL (60 caps / 25 days)
KADIAN CAP 150MG CR
3
QL (60 caps / 25 days)
KADIAN CAP 200MG CR
3
QL (60 caps / 25 days)
LAZANDA SPR 100MCG
3
QL (8 bottles per 25
days), PA
LAZANDA SPR 400MCG
3
QL (8 bottles per 25
days), PA
levorphanol tartrate tab 2 mg
1
QL (180 tabs / 25 days)
meperidine hcl oral soln 50 mg/5ml
1
QL (30 mL / 25 days)
meperidine hcl tab 50 mg
1
QL (15 tabs / 25 days)
meperidine hcl tab 100 mg
1
QL (15 tabs / 25 days)
methadone hcl conc 10 mg/ml
1
methadone hcl soln 5 mg/5ml
1
methadone hcl soln 10 mg/5ml
1
methadone hcl tab 5 mg
1
QL (120 tabs / 25 days)
methadone hcl tab 10 mg
1
QL (120 tabs / 25 days)
methadone hcl tab for oral susp 40 mg
1
QL (9 tabs / 25 days)
METHADONE INJ 10MG/ML
3
methadose tab 5mg
1
QL (120 tabs / 25 days)
methadose tab 10mg
1
QL (120 tabs / 25 days)
methadose tab 40mg
1
QL (9 tabs / 25 days)
MORPHINE SUL INJ 2MG/ML
3
MORPHINE SUL INJ 4MG/ML
3
MORPHINE SUL INJ 5MG/ML
3
MORPHINE SUL INJ 8MG/ML
3
MORPHINE SUL INJ 150/30ML
3
MORPHINE SUL SUP 30MG
2
QL (180 supp / 25 days)
morphine sulfate (concentrate) oral soln 20 1
QL (180 mL / 25 days)
mg/ml
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
9
Drug Name
morphine sulfate beads cap sr 24hr 30 mg
morphine sulfate beads cap sr 24hr 45 mg
morphine sulfate beads cap sr 24hr 60 mg
morphine sulfate beads cap sr 24hr 75 mg
morphine sulfate beads cap sr 24hr 90 mg
morphine sulfate beads cap sr 24hr 120
mg
morphine sulfate cap sr 24hr 10 mg
morphine sulfate cap sr 24hr 20 mg
morphine sulfate cap sr 24hr 30 mg
morphine sulfate cap sr 24hr 50 mg
morphine sulfate cap sr 24hr 60 mg
morphine sulfate cap sr 24hr 80 mg
morphine sulfate cap sr 24hr 100 mg
morphine sulfate inj 2 mg/ml
morphine sulfate inj 8 mg/ml
morphine sulfate inj 10 mg/ml
morphine sulfate inj 15 mg/ml
morphine sulfate inj pf 0.5 mg/ml
morphine sulfate inj pf 1 mg/ml
morphine sulfate iv soln 1 mg/ml
morphine sulfate iv soln 25 mg/ml
morphine sulfate iv soln 50 mg/ml
morphine sulfate iv soln pf 10 mg/ml
morphine sulfate iv soln pf 15 mg/ml
morphine sulfate oral soln 10 mg/5ml
morphine sulfate oral soln 20 mg/5ml
morphine sulfate suppos 5 mg
morphine sulfate suppos 10 mg
morphine sulfate suppos 20 mg
morphine sulfate tab 15 mg
morphine sulfate tab 30 mg
morphine sulfate tab cr 15 mg
morphine sulfate tab cr 30 mg
morphine sulfate tab cr 60 mg
morphine sulfate tab cr 100 mg
morphine sulfate tab cr 200 mg
NUCYNTA ER TAB 50MG
NUCYNTA ER TAB 100MG
NUCYNTA ER TAB 150MG
NUCYNTA ER TAB 200MG
NUCYNTA ER TAB 250MG
NUCYNTA TAB 50MG
NUCYNTA TAB 75MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
1
QL (60 caps / 25 days)
1
QL (60 caps / 25 days)
1
QL (60 caps / 25 days)
1
QL (60 caps / 25 days)
1
QL (60 caps / 25 days)
1
QL (60 caps / 25 days)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
ST - Step Therapy
QL
QL
QL
QL
QL
QL
QL
(60
(60
(60
(60
(60
(60
(60
caps
caps
caps
caps
caps
caps
caps
/
/
/
/
/
/
/
25
25
25
25
25
25
25
days)
days)
days)
days)
days)
days)
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(900 mL / 25 days)
(900 mL / 25 days)
(180 supp / 25 days)
(180 supp / 25 days)
(180 supp / 25 days)
(180 tabs / 25 days)
(180 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(360 tabs / 25 days)
(240 tabs / 25 days)
PA** - PA Applies if
10
Drug Name
NUCYNTA TAB 100MG
OPANA ER TAB 5MG
OPANA ER TAB 7.5MG
OPANA ER TAB 10MG
OPANA ER TAB 15MG
OPANA ER TAB 20MG
OPANA ER TAB 30MG
OPANA ER TAB 40MG
OXECTA TAB 5MG
OXECTA TAB 7.5MG
oxycodone hcl cap 5 mg
oxycodone hcl conc 100 mg/5ml (20
mg/ml)
oxycodone hcl soln 5 mg/5ml
oxycodone hcl tab 5 mg
oxycodone hcl tab 10 mg
oxycodone hcl tab 15 mg
oxycodone hcl tab 20 mg
oxycodone hcl tab 30 mg
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
oxymorphone hcl tab 5 mg
oxymorphone hcl tab 10 mg
oxymorphone hcl tab sr 12hr 5 mg
oxymorphone hcl tab sr 12hr 7.5 mg
oxymorphone hcl tab sr 12hr 10 mg
oxymorphone hcl tab sr 12hr 15 mg
oxymorphone hcl tab sr 12hr 20 mg
oxymorphone hcl tab sr 12hr 30 mg
oxymorphone hcl tab sr 12hr 40 mg
SUBSYS SPR 100MCG
Drug Tier Requirements/Limits
3
QL (180 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (120 tabs / 25 days)
3
QL (180 tabs / 25 days)
3
QL (180 tabs / 25 days)
1
QL (180 caps / 25 days)
1
QL (180 mL / 25 days)
1
1
1
1
1
1
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
3
SUBSYS SPR 200MCG
3
SUBSYS SPR 400MCG
3
SUBSYS SPR 600MCG
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (900 mL / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (180 tabs / 25 days)
QL (180 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (120 Units per 25
days), PA
QL (120 Units per 25
days), PA
QL (120 Units per 25
days), PA
QL (120 Units per 25
days), PA
PA** - PA Applies if
11
Drug Name
SUBSYS SPR 800MCG
SUBSYS SPR 1200MCG
SUBSYS SPR 1600MCG
tramadol
tramadol
tramadol
tramadol
hcl
hcl
hcl
hcl
tab
tab
tab
tab
50 mg
sr 24hr 100 mg
sr 24hr 200 mg
sr 24hr 300 mg
Drug Tier Requirements/Limits
3
QL (120 Units per 25
days), PA
3
QL (120 Units per 25
days), PA
3
QL (120 Units per 25
days), PA
1
QL (240 tabs / 25 days)
1
QL (30 tabs / 25 days)
1
QL (30 tabs / 25 days)
1
QL (30 tabs / 25 days)
Opioid Combinations
acetaminophen w/ codeine soln 120-12
1
mg/5ml
acetaminophen w/ codeine tab 300-15 mg 1
acetaminophen w/ codeine tab 300-30 mg 1
acetaminophen w/ codeine tab 300-60 mg 1
CAPITAL/COD SUS 120-12/5
3
endocet tab 5-325mg
1
endocet tab 7.5-325
1
endocet tab 10-325mg
1
HYDROCO/APAP SOL 10-325MG
3
hydrocodone-acetaminophen soln 7.5-325 1
mg/15ml
hydrocodone-acetaminophen tab 2.5-325 1
mg
hydrocodone-acetaminophen tab 5-300 mg 1
hydrocodone-acetaminophen tab 5-325 mg 1
hydrocodone-acetaminophen tab 7.5-300 1
mg
hydrocodone-acetaminophen tab 7.5-325 1
mg
hydrocodone-acetaminophen tab 10-300 1
mg
hydrocodone-acetaminophen tab 10-325 1
mg
oxycodone w/ acetaminophen tab 2.5-325 1
mg
oxycodone w/ acetaminophen tab 5-325
1
mg
oxycodone w/ acetaminophen tab 7.5-325 1
mg
oxycodone w/ acetaminophen tab 10-325 1
mg
oxycodone-aspirin tab 4.8355-325 mg
1
oxycodone-ibuprofen tab 5-400 mg
1
PRIMLEV TAB 5-300MG
3
PRIMLEV TAB 7.5-300
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (5000 mL / 25 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
(400 tabs
(400 tabs
(400 tabs
(5000 mL
(360 tabs
(360 tabs
(360 tabs
(5500 mL
(5500 mL
/
/
/
/
/
/
/
/
/
25
25
25
25
25
25
25
25
25
days)
days)
days)
days)
days)
days)
days)
days)
days)
QL (360 tabs / 25 days)
QL (400 tabs / 25 days)
QL (360 tabs / 25 days)
QL (400 tabs / 25 days)
QL (360 tabs / 25 days)
QL (400 tabs / 25 days)
QL (360 tabs / 25 days)
QL (360 tabs / 25 days)
QL (360 tabs / 25 days)
QL (360 tabs / 25 days)
QL (360 tabs / 25 days)
QL
QL
QL
QL
(28 tabs / 25 days)
(28 tabs / 25 days)
(400 tabs / 25 days)
(400 tabs / 25 days)
PA** - PA Applies if
12
Drug Name
PRIMLEV TAB 10-300MG
ROXICET SOL 5-325/5
roxicet tab 5-325mg
vicodin es tab 7.5-300
vicodin hp tab 10-300mg
vicodin tab 5-300mg
ZAMICET SOL 10-325MG
Drug Tier Requirements/Limits
3
QL (400 tabs / 25 days)
3
QL (1800 mL / 25 days)
1
QL (360 tabs / 25 days)
1
QL (400 tabs / 25 days)
1
QL (400 tabs / 25 days)
1
QL (400 tabs / 25 days)
3
QL (5500 mL / 25 days)
Opioid Partial Agonists
buprenorphine hcl inj 0.3 mg/ml (base
1
equiv)
buprenorphine hcl sl tab 2 mg (base equiv) 1
buprenorphine hcl sl tab 8 mg (base equiv) 1
butorphanol tartrate inj 1 mg/ml
1
butorphanol tartrate inj 2 mg/ml
1
butorphanol tartrate nasal soln 10 mg/ml 1
BUTRANS DIS 5MCG/HR
3
BUTRANS DIS 10MCG/HR
3
BUTRANS DIS 15MCG/HR
3
BUTRANS DIS 20MCG/HR
3
nalbuphine hcl inj 10 mg/ml
1
nalbuphine hcl inj 20 mg/ml
1
SUBOXONE MIS 2-0.5MG
2
SUBOXONE MIS 4-1MG
2
SUBOXONE MIS 8-2MG
2
SUBOXONE MIS 12-3MG
2
TALWIN INJ 30MG/ML
3
PA
PA
QL (2 bottles / 25 days)
PA
PA
PA
PA
PA
PA
PA
PA
ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL-50 TAB 50MG
oxandrolone tab 2.5 mg
oxandrolone tab 10 mg
3
1
1
PA
PA
PA
ANDRODERM DIS 2.5MG/24
2
ANDRODERM DIS 2MG/24HR
2
ANDRODERM DIS 4MG/24HR
2
ANDRODERM DIS 5MG/24HR
2
android cap 10mg
1
ANDROXY TAB 10MG
3
AXIRON SOL 30MG/ACT
2
danazol cap 50 mg
1
danazol cap 100 mg
1
danazol cap 200 mg
1
testosterone cypionate im in oil 100 mg/ml 1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Androgens
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
13
Drug Name
Drug Tier Requirements/Limits
testosterone cypionate im in oil 200 mg/ml 1
PA
testosterone enanthate im in oil 200 mg/ml1
PA
ANORECTAL AGENTS
Intrarectal Steroids
colocort ene 100mg
hydrocortisone enema 100 mg/60ml
1
1
Rectal Steroids
anucort-hc sup 25mg
hemril-30 sup 30mg
procto-pak cre 1%
proctocream cre -hc 2.5%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%
1
1
1
1
1
1
Vasodilating Agents
RECTIV OIN 0.4%
3
ANTHELMINTICS
Anthelmintics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
mebendazole chew tab 100 mg
STROMECTOL TAB 3MG
2
3
1
2
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam for inj 1 gm
aztreonam for inj 2 gm
CAYSTON INH 75MG
FLAGYL ER TAB 750MG
metronidazole cap 375 mg
metronidazole in nacl 0.79% iv soln 500
mg/100ml
metronidazole tab 250 mg
metronidazole tab 500 mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
PRIMSOL SOL 50MG/5ML
tinidazole tab 250 mg
tinidazole tab 500 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg
vancomycin hcl cap 250 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
1
1
4
3
1
1
1
1
3
3
2
1
1
1
1
1
ST - Step Therapy
PA
ST; PA**
ST; PA**
PA** - PA Applies if
14
Drug Name
vancomycin hcl for inj
vancomycin hcl for inj
vancomycin hcl for inj
vancomycin hcl for inj
VIBATIV INJ 250MG
VIBATIV INJ 750MG
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
Drug Tier Requirements/Limits
1
1
1
1
3
3
2
2
PA
10 gm
500 mg
1000 mg
5000 mg
Anti-infective Misc. - Combinations
e.s.p. sus 200-600
1
erythromycin-sulfisoxazole for susp 200- 1
600 mg/5ml
sulfamethoxazole-trimethoprim iv soln
1
400-80 mg/5ml
sulfamethoxazole-trimethoprim susp 200- 1
40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab 800- 1
160 mg
Antiprotozoal Agents
ALINIA SUS 100/5ML
ALINIA TAB 500MG
MEPRON SUS
2
2
3
Carbapenems
DORIBAX INJ 250MG
DORIBAX INJ 500MG
imipenem-cilastatin intravenous for soln
250 mg
imipenem-cilastatin intravenous for soln
500 mg
INVANZ INJ 1GM
meropenem iv for soln 1 gm
meropenem iv for soln 500 mg
3
3
1
1
3
1
1
Chloramphenicols
chloramphenicol sodium succinate for iv inj 1
1 gm
Cyclic Lipopeptides
CUBICIN SOL 500MG
3
Glycylcyclines
TYGACIL INJ 50MG
3
Ketolides
KETEK TAB 300MG
KETEK TAB 400MG
3
3
Leprostatics
dapsone tab 25 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
15
Drug Name
dapsone tab 100 mg
Drug Tier Requirements/Limits
1
Lincosamides
clindamycin hcl cap 75 mg
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
clindamycin phosphate inj 9 gm/60ml
clindamycin phosphate inj 300 mg/2ml
clindamycin phosphate inj 600 mg/4ml
clindamycin phosphate inj 900 mg/6ml
clindamycin phosphate iv soln 300 mg/2ml
clindamycin phosphate iv soln 600 mg/4ml
clindamycin phosphate iv soln 900 mg/6ml
LINCOCIN INJ 300MG/ML
1
1
1
1
1
1
1
1
1
1
1
3
Oxazolidinones
ZYVOX SOL 2MG/ML
ZYVOX SUS 100MG/5M
ZYVOX TAB 600MG
3
2
2
Polymyxins
polymyxin b sulfate for inj 500000 unit
1
ANTIANGINAL AGENTS
Antianginals-Other
RANEXA TAB 500MG
RANEXA TAB 1000MG
2
2
ST; PA**
ST; PA**
Nitrates
DILATRATE SR CAP 40MG
3
isochron tab 40mg cr
1
isoditrate tab 40mg er
1
ISORDIL TAB 40MG
2
isosorbide dinitrate sl tab 2.5 mg
1
isosorbide dinitrate sl tab 5 mg
1
isosorbide dinitrate tab 5 mg
1
isosorbide dinitrate tab 10 mg
1
isosorbide dinitrate tab 20 mg
1
isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
isosorbide mononitrate tab sr 24hr 30 mg 1
isosorbide mononitrate tab sr 24hr 60 mg 1
isosorbide mononitrate tab sr 24hr 120 mg 1
minitran dis 0.1mg/hr
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
16
Drug Name
minitran dis 0.2mg/hr
minitran dis 0.4mg/hr
minitran dis 0.6mg/hr
NITRO-BID OIN 2%
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
NITROGLYCER INJ 5MG/ML
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
nitroglycerin iv soln 100 mcg/ml in d5w
nitroglycerin iv soln 200 mcg/ml in d5w
nitroglycerin iv soln 400 mcg/ml in d5w
nitroglycerin td patch 24hr 0.1 mg/hr
nitroglycerin td patch 24hr 0.2 mg/hr
nitroglycerin td patch 24hr 0.4 mg/hr
nitroglycerin td patch 24hr 0.6 mg/hr
nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
NITROMIST AER 400MCG
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
Drug Tier Requirements/Limits
1
1
1
3
2
2
3
1
1
1
1
1
1
1
1
1
1
1
3
2
2
2
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
hydroxyzine hcl im soln 25 mg/ml
1
1
1
1
1
1
hydroxyzine hcl im soln 50 mg/ml
1
hydroxyzine hcl syrup 10 mg/5ml
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
17
Drug Name
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
hydroxyzine pamoate cap 100 mg
meprobamate tab 200 mg
meprobamate tab 400 mg
Drug Tier Requirements/Limits
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
1
Benzodiazepines
ALPRAZOLAM CON 1 MG/ML
2
alprazolam orally disintegrating tab 0.5 mg 1
alprazolam orally disintegrating tab 0.25
1
mg
alprazolam orally disintegrating tab 1 mg 1
alprazolam orally disintegrating tab 2 mg 1
alprazolam tab 0.5 mg
1
alprazolam tab 0.25 mg
1
alprazolam tab 1 mg
1
alprazolam tab 2 mg
1
clorazepate dipotassium tab 3.75 mg
1
clorazepate dipotassium tab 7.5 mg
1
clorazepate dipotassium tab 15 mg
1
DIAZEPAM CON 5MG/ML
2
diazepam soln 1 mg/ml
1
diazepam tab 2 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (120 mL / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(90 tabs / 25 days)
(60 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(240 mL / 25 days)
(1200 mL / 25 days)
(120 tabs / 25 days)
PA** - PA Applies if
18
Drug Name
diazepam tab 5 mg
diazepam tab 10 mg
lorazepam conc 2 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
Drug Tier Requirements/Limits
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (90 mL / 25 days)
1
QL (150 tabs / 25 days)
1
QL (150 tabs / 25 days)
1
QL (150 tabs / 25 days)
1
QL (120 caps / 25 days)
1
QL (120 caps / 25 days)
1
QL (120 caps / 25 days)
ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
NORPACE CAP 100MG CR
NORPACE CAP 150MG CR
procainamide hcl inj 100 mg/ml
PROCAINAMIDE INJ 500MG/ML
quinidine gluconate tab cr 324 mg
quinidine sulfate tab cr 300 mg
1
1
2
2
1
3
1
1
Antiarrhythmics Type I-B
lidocaine hcl iv inj 10 mg/ml
lidocaine hcl iv inj 20 mg/ml
lidocaine iv infusion in d5w inj 4 mg/ml
lidocaine iv infusion in d5w inj 8 mg/ml
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg
1
1
1
1
1
1
1
Antiarrhythmics Type I-C
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
propafenone hcl cap sr 12hr 225 mg
propafenone hcl cap sr 12hr 325 mg
propafenone hcl cap sr 12hr 425 mg
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
1
1
1
1
1
1
1
1
1
Antiarrhythmics Type III
amiodarone hcl inj 150 mg/3ml (50
mg/ml)
amiodarone hcl inj 450 mg/9ml (50
mg/ml)
amiodarone hcl inj 900 mg/18ml (50
mg/ml)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
ST - Step Therapy
PA** - PA Applies if
19
Drug Name
amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
MULTAQ TAB 400MG
NEXTERONE INJ
pacerone tab 100mg
pacerone tab 200mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
Drug Tier Requirements/Limits
1
1
3
PA
3
1
1
4
PA
4
PA
4
PA
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Anti-Inflammatory Agents
cromolyn sodium soln nebu 20 mg/2ml
1
QL (2 boxes / 25 days)
2
QL (2 inhalers / 25
1
2
days)
QL (5 boxes / 25 days)
QL (30 caps / 25 days)
Bronchodilators - Anticholinergics
ATROVENT HFA AER 17MCG
ipratropium bromide inhal soln 0.02%
SPIRIVA CAP HANDIHLR
Leukotriene Modulators
montelukast sodium chew tab 4 mg (base 1
equiv)
montelukast sodium chew tab 5 mg (base 1
equiv)
montelukast sodium oral granules packet 4 1
mg (base equiv)
montelukast sodium tab 10 mg (base
1
equiv)
zafirlukast tab 10 mg
1
zafirlukast tab 20 mg
1
ZYFLO CR TAB 600MG
3
Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TAB 500MCG
3
PA
ALVESCO AER 80MCG
3
ALVESCO AER 160MCG
3
ASMANEX 30 AER 110MCG
2
ASMANEX 30 AER 220MCG
2
ASMANEX 60 AER 220MCG
2
ASMANEX 120 AER 220MCG
2
QL (3 inhalers / 25
days), ST
QL (2 inhalers / 25
days), ST
QL (2 inhalers / 25
days)
QL (4 inhalers per 25
days)
QL (2 inhalers per 25
days)
QL (1 inhaler per 25
days)
Steroid Inhalants
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
20
Drug Name
budesonide inhalation susp 0.5 mg/2ml
budesonide inhalation susp 0.25 mg/2ml
FLOVENT DISK AER 50MCG
FLOVENT DISK AER 100MCG
FLOVENT DISK AER 250MCG
FLOVENT HFA AER 44MCG
FLOVENT HFA AER 110MCG
FLOVENT HFA AER 220MCG
PULMICORT INH 90MCG
PULMICORT INH 180MCG
PULMICORT SUS 1MG/2ML
QVAR AER 40MCG
QVAR AER 80MCG
Drug Tier Requirements/Limits
1
QL (3 inhalers / 25
days)
1
QL (3 boxes / 25 days)
3
QL (2 inhalers / 25
days), ST
3
QL (4 inhalers / 25
days), ST
3
QL (4 inhalers / 25
days), ST
3
QL (2 inhalers / 25
days), ST
3
QL (2 inhalers / 25
days), ST
3
QL (2 inhalers / 25
days), ST
3
QL (3 inhalers / 25
days), ST
3
QL (3 inhalers / 25
days), ST
3
QL (1 box / 25 days),
ST
2
QL (2 inhalers / 25
days)
2
QL (3 boxes / 25 days)
Sympathomimetics
ADVAIR DISKU AER 100/50
2
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.63 mg/3ml
1
(base equiv)
albuterol sulfate soln nebu 0.083% (2.5
1
mg/3ml)
albuterol sulfate soln nebu 1.25 mg/3ml
1
(base equiv)
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
albuterol sulfate tab sr 12hr 4 mg
1
albuterol sulfate tab sr 12hr 8 mg
1
ARCAPTA CAP 75MCG
3
BREO ELLIPTA INH 100-25
3
BROVANA NEB 15MCG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
ST - Step Therapy
QL (1 inhaler / 25 days),
ST; PA**; Covered for
ages 4-11
QL (3 boxes / 25 days)
QL (5 boxes / 25 days)
QL (5 boxes / 25 days)
QL (5 boxes / 25 days)
QL (1 blister / 25 days)
QL (1 Package / 25
days), PA
QL (2 boxes / 25 days)
PA** - PA Applies if
21
Drug Name
COMBIVENT AER RESPIMAT
DULERA AER 100-5MCG
DULERA AER 200-5MCG
epinephrine hcl inj 1 mg/ml
epinephrine hcl soln prefilled syringe 0.1
mg/ml
FORADIL CAP AEROLIZE
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv)
levalbuterol hcl soln nebu 0.63 mg/3ml
(base equiv)
levalbuterol hcl soln nebu 1.25 mg/3ml
(base equiv)
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
metaproterenol sulfate syrup 10 mg/5ml
metaproterenol sulfate tab 10 mg
metaproterenol sulfate tab 20 mg
PERFOROMIST NEB 20MCG
PROAIR HFA AER
Drug Tier Requirements/Limits
2
QL (2 inhalers / 25
days)
2
QL (1 inhaler / 25 days),
ST; PA**
2
QL (1 inhaler / 25 days),
ST; PA**
1
1
2
1
QL (60 caps / 25 days)
QL (6 boxes / 25 days)
1
QL (4 boxes / 25 days)
1
QL (4 boxes / 25 days)
1
QL (4 boxes / 25 days)
1
QL (3 boxes / 25 days)
1
1
1
2
2
SEREVENT DIS AER 50MCG
SYMBICORT AER 80-4.5
3
2
SYMBICORT AER 160-4.5
2
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
XOPENEX HFA AER
1
1
1
3
QL (2 boxes / 25 days)
QL (2 inhalers / 25
days)
QL (1 inhaler / 25 days)
QL (1 inhaler / 25 days),
ST; PA**
QL (1 inhaler / 25 days),
ST; PA**
QL (5 boxes / 25 days),
ST
Xanthines
aminophylline inj 25 mg/ml
ELIXOPHYLLIN ELX 80/15ML
LUFYLLIN TAB 200MG
LUFYLLIN TAB 400MG
THEO-24 CAP 100MG CR
THEO-24 CAP 200MG CR
THEO-24 CAP 300MG CR
THEO-24 CAP 400MG ER
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
3
3
3
3
3
3
3
ST - Step Therapy
PA** - PA Applies if
22
Drug Name
theochron tab 100mg cr
theochron tab 200mg cr
theochron tab 300mg cr
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg
theophylline tab sr 12hr 200 mg
theophylline tab sr 12hr 300 mg
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 400 mg
theophylline tab sr 24hr 600 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
ANTICOAGULANTS
Coumarin Anticoagulants
COUMADIN INJ 5 MG
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
jantoven tab 10mg
warfarin sodium tab 1 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
warfarin sodium tab 10 mg
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Direct Factor Xa Inhibitors
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
3
3
2
2
2
Heparins And Heparinoid-Like Agents
enoxaparin
enoxaparin
enoxaparin
enoxaparin
enoxaparin
sodium
sodium
sodium
sodium
sodium
inj
inj
inj
inj
inj
30 mg/0.3ml
40 mg/0.4ml
60 mg/0.6ml
80 mg/0.8ml
100 mg/ml
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
ST - Step Therapy
QL
QL
QL
QL
QL
(60
(60
(60
(60
(60
mL
mL
mL
mL
mL
/
/
/
/
/
90
90
90
90
90
days)
days)
days)
days)
days)
PA** - PA Applies if
23
Drug Name
Drug Tier Requirements/Limits
enoxaparin sodium inj 120 mg/0.8ml
1
QL (60 mL / 90 days)
enoxaparin sodium inj 150 mg/ml
1
QL (60 mL / 90 days)
enoxaparin sodium inj 300 mg/3ml
1
QL (60 mL / 90 days)
fondaparinux sodium inj 2.5 mg/0.5ml
1
QL (30 mL / 90 days)
fondaparinux sodium inj 5 mg/0.4ml
1
QL (30 mL / 90 days)
fondaparinux sodium inj 7.5 mg/0.6ml
1
QL (30 mL / 90 days)
fondaparinux sodium inj 10 mg/0.8ml
1
QL (30 mL / 90 days)
FRAGMIN INJ 2500/0.2
3
QL (30 mL / 90 days)
FRAGMIN INJ 5000/0.2
3
QL (30 mL / 90 days)
FRAGMIN INJ 7500/0.3
3
QL (30 mL / 90 days)
FRAGMIN INJ 10000/ML
3
QL (30 mL / 90 days)
FRAGMIN INJ 12500UNT
3
QL (30 mL / 90 days)
FRAGMIN INJ 15000UNT
3
QL (30 mL / 90 days)
FRAGMIN INJ 18000UNT
3
QL (30 mL / 90 days)
FRAGMIN INJ 25000/ML
3
QL (30 mL / 90 days)
heparin sodium (porcine) inj 1000 unit/ml 1
heparin sodium (porcine) inj 5000 unit/ml 1
heparin sodium (porcine) inj 10000 unit/ml 1
heparin sodium (porcine) inj 20000 unit/ml 1
heparin sodium (porcine) pf inj 5000
1
unit/0.5ml
Thrombin Inhibitors
argatroban inj 100 mg/ml (concentrate for 1
iv infusion)
ARGATROBAN INJ 125/125
3
PRADAXA CAP 75MG
2
PRADAXA CAP 150MG
2
ANTICONVULSANTS
Anticonvulsants - Benzodiazepines
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
ONFI SUS 2.5MG/ML
ONFI TAB 5MG
ONFI TAB 10MG
ONFI TAB 20MG
1
1
1
3
3
3
3
PA
PA
PA
PA
Anticonvulsants - Misc.
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepine cap sr 12hr 100 mg
carbamazepine cap sr 12hr 200 mg
carbamazepine cap sr 12hr 300 mg
carbamazepine chew tab 100 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
1
1
1
1
ST - Step Therapy
PA
PA
PA
PA** - PA Applies if
24
Drug Name
Drug Tier Requirements/Limits
carbamazepine susp 100 mg/5ml
1
carbamazepine tab 200 mg
1
carbamazepine tab sr 12hr 200 mg
1
carbamazepine tab sr 12hr 400 mg
1
epitol tab 200mg
1
gabapentin cap 100 mg
1
gabapentin cap 300 mg
1
gabapentin cap 400 mg
1
gabapentin oral soln 250 mg/5ml
1
gabapentin tab 600 mg
1
gabapentin tab 800 mg
1
LAMICTAL CHW 2MG
2
LAMICTAL KIT START 35
3
LAMICTAL KIT START 49
3
LAMICTAL KIT START 98
3
LAMICTAL ODT KIT
3
LAMICTAL ODT TAB 25MG
3
LAMICTAL ODT TAB 50MG
3
LAMICTAL ODT TAB 100MG
3
LAMICTAL ODT TAB 200MG
3
LAMICTAL XR KIT
3
lamotrigine tab 25 mg
1
lamotrigine tab 100 mg
1
lamotrigine tab 150 mg
1
lamotrigine tab 200 mg
1
lamotrigine tab chewable dispersible 5 mg 1
lamotrigine tab chewable dispersible 25 mg1
lamotrigine tab sr 24hr 25 mg
1
lamotrigine tab sr 24hr 50 mg
1
lamotrigine tab sr 24hr 100 mg
1
lamotrigine tab sr 24hr 200 mg
1
lamotrigine tab sr 24hr 250 mg
1
lamotrigine tab sr 24hr 300 mg
1
LEVETIRACETA INJ 5MG/ML
3
LEVETIRACETA INJ 10MG/ML
3
LEVETIRACETA INJ 15MG/ML
3
levetiracetam inj 500 mg/5ml (100 mg/ml) 1
levetiracetam oral soln 100 mg/ml
1
levetiracetam tab 250 mg
1
levetiracetam tab 500 mg
1
levetiracetam tab 750 mg
1
levetiracetam tab 1000 mg
1
levetiracetam tab sr 24hr 500 mg
1
levetiracetam tab sr 24hr 750 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
25
Drug Name
LYRICA CAP 25MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 300MG
LYRICA SOL 20MG/ML
oxcarbazepine susp 300 mg/5ml (60
mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
primidone tab 50 mg
primidone tab 250 mg
TEGRETOL-XR TAB 100MG
topiragen tab 25mg
topiragen tab 50mg
topiragen tab 100mg
topiragen tab 200mg
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg
Drug Tier Requirements/Limits
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
ST; PA**
1
1
1
1
3
3
3
3
1
1
2
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Carbamates
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
ST - Step Therapy
PA** - PA Applies if
26
Drug Name
Drug Tier Requirements/Limits
GABA Modulators
GABITRIL TAB 12MG
GABITRIL TAB 16MG
SABRIL POW 500MG
SABRIL TAB 500MG
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
2
2
4
4
1
1
PA
PA
Hydantoins
DILANTIN CAP 30MG
fosphenytoin sodium inj 100 mg/2ml
(phenytoin equiv)
fosphenytoin sodium inj 500 mg/10ml
(phenytoin equiv)
PEGANONE TAB 250MG
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 mg
phenytoin sodium inj 50 mg/ml
phenytoin susp 125 mg/5ml
3
1
1
3
1
1
1
1
1
1
Succinimides
CELONTIN CAP 300MG
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
3
1
1
Valproic Acid
divalproex sodium cap sprinkle 125 mg
divalproex sodium tab delayed release 125
mg
divalproex sodium tab delayed release 250
mg
divalproex sodium tab delayed release 500
mg
divalproex sodium tab sr 24 hr 250 mg
divalproex sodium tab sr 24 hr 500 mg
STAVZOR CAP 125MG
STAVZOR CAP 250MG
STAVZOR CAP 500MG
valproate sodium inj 100 mg/ml
valproate sodium syrup 250 mg/5ml (base
equiv)
valproic acid cap 250 mg
1
1
1
1
1
1
3
3
3
1
1
1
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine orally disintegrating tab 15 mg 1
mirtazapine orally disintegrating tab 30 mg 1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
27
Drug Name
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
Drug Tier Requirements/Limits
orally disintegrating tab 45 mg 1
tab 7.5 mg
1
tab 15 mg
1
tab 30 mg
1
tab 45 mg
1
Antidepressants - Misc.
APLENZIN TAB 174MG
APLENZIN TAB 348MG
APLENZIN TAB 522MG
budeprion tab 100mg sr
budeprion tab 150mg sr
budeprion xl tab 150mg
budeprion xl tab 300mg
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab sr 12hr 100
bupropion hcl tab sr 12hr 150
bupropion hcl tab sr 12hr 200
bupropion hcl tab sr 24hr 150
bupropion hcl tab sr 24hr 300
maprotiline hcl tab 25 mg
maprotiline hcl tab 50 mg
maprotiline hcl tab 75 mg
mg
mg
mg
mg
mg
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Modified Cyclics
nefazodone hcl tab 50 mg
nefazodone hcl tab 100 mg
nefazodone hcl tab 150 mg
nefazodone hcl tab 200 mg
nefazodone hcl tab 250 mg
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
1
1
1
1
1
1
1
1
1
3
3
3
3
ST
ST
ST
ST
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMSAM DIS 12MG/24H
MARPLAN TAB 10MG
phenelzine sulfate tab 15 mg
tranylcypromine sulfate tab 10 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
3
1
1
ST - Step Therapy
PA** - PA Applies if
28
Drug Name
Drug Tier Requirements/Limits
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram hydrobromide oral soln 10
mg/5ml
citalopram hydrobromide tab 10 mg (base
equiv)
citalopram hydrobromide tab 20 mg (base
equiv)
citalopram hydrobromide tab 40 mg (base
equiv)
escitalopram oxalate soln 5 mg/5ml (base
equiv)
escitalopram oxalate tab 5 mg (base
equiv)
escitalopram oxalate tab 10 mg (base
equiv)
escitalopram oxalate tab 20 mg (base
equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl cap delayed release 90 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
FLUOXETINE TAB 60MG
fluvoxamine maleate cap sr 24hr 100 mg
fluvoxamine maleate cap sr 24hr 150 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
paroxetine hcl tab sr 24hr 12.5 mg
paroxetine hcl tab sr 24hr 25 mg
paroxetine hcl tab sr 24hr 37.5 mg
PAXIL SUS 10MG/5ML
PEXEVA TAB 10MG
PEXEVA TAB 20MG
PEXEVA TAB 30MG
PEXEVA TAB 40MG
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
2
3
3
3
3
1
1
1
1
ST - Step Therapy
ST
ST
ST
ST
PA** - PA Applies if
29
Drug Name
Drug Tier Requirements/Limits
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
duloxetine hcl cap 20 mg
duloxetine hcl cap 30 mg
duloxetine hcl cap 60 mg
PRISTIQ TAB 50MG
PRISTIQ TAB 100MG
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
venlafaxine hcl tab sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 150 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 225 mg (base
equivalent)
1
1
1
3
3
1
ST
ST
1
1
1
1
1
1
1
1
1
1
1
Tricyclic Agents
amitriptyline hcl tab 10 mg
1
amitriptyline hcl tab 25 mg
1
amitriptyline hcl tab 50 mg
1
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
amoxapine tab 25 mg
1
1
1
1
amoxapine tab 50 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
PA** - PA Applies if
30
Drug Name
amoxapine tab 100 mg
amoxapine tab 150 mg
clomipramine hcl cap 25 mg
clomipramine hcl cap 50 mg
clomipramine hcl cap 75 mg
desipramine hcl tab 10 mg
desipramine hcl tab 25 mg
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
doxepin hcl cap 10 mg
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
ST - Step Therapy
PA** - PA Applies if
31
Drug Name
doxepin hcl cap 75 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
imipramine hcl tab 10 mg
imipramine hcl tab 25 mg
imipramine hcl tab 50 mg
imipramine pamoate cap 75 mg
imipramine pamoate cap 100 mg
imipramine pamoate cap 125 mg
imipramine pamoate cap 150 mg
nortriptyline hcl cap 10 mg
Drug Tier Requirements/Limits
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (360 mL / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
1
1
QL (60 caps / 25 days);
nortriptyline hcl cap 25 mg
1
nortriptyline hcl cap 50 mg
1
nortriptyline hcl cap 75 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL applies to members
age 65 and older
QL (60 caps / 25 days);
QL applies to members
age 65 and older
QL (60 caps / 25 days);
QL applies to members
age 65 and older
QL (30 caps / 25 days);
QL applies to members
age 65 and older
PA** - PA Applies if
32
Drug Name
nortriptyline hcl soln 10 mg/5ml
Drug Tier Requirements/Limits
1
QL (3 bottles / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
3
QL (60 caps / 25 days);
QL applies to members
age 65 and older
3
QL (60 caps / 25 days);
QL applies to members
age 65 and older
3
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURMONTIL CAP 100MG
trimipramine maleate cap 25 mg
trimipramine maleate cap 50 mg
trimipramine maleate cap 100 mg
ANTIDIABETICS
Alpha-Glucosidase Inhibitors
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
GLYSET TAB 25MG
GLYSET TAB 50MG
GLYSET TAB 100MG
1
1
1
3
3
3
Antidiabetic - Amylin Analogs
SYMLIN INJ 600MCG
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
3
3
3
PA
PA
PA
Antidiabetic Combinations
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
ST - Step Therapy
PA** - PA Applies if
33
Drug Name
glipizide-metformin hcl tab 5-500 mg
glyburide-metformin tab 1.25-250 mg
Drug Tier Requirements/Limits
1
1
PA; High Risk
Medications require PA
for members age 65 and
older
glyburide-metformin tab 2.5-500 mg
1
PA; High Risk
Medications require PA
for members age 65 and
older
glyburide-metformin tab 5-500 mg
1
PA; High Risk
Medications require PA
for members age 65 and
older
JANUMET TAB 50-500MG
2
JANUMET TAB 50-1000
2
JANUMET XR TAB 50-500MG
2
JANUMET XR TAB 50-1000
2
JANUMET XR TAB 100-1000
2
JENTADUETO TAB 2.5-500
2
JENTADUETO TAB 2.5-850
2
JENTADUETO TAB 2.5-1000
2
pioglitazone hcl-glimepiride tab 30-2 mg
1
pioglitazone hcl-glimepiride tab 30-4 mg
1
pioglitazone hcl-metformin hcl tab 15-500 1
mg
pioglitazone hcl-metformin hcl tab 15-850 1
mg
Biguanides
metformin
metformin
metformin
metformin
metformin
metformin
metformin
mg
hcl
hcl
hcl
hcl
hcl
hcl
hcl
tab
tab
tab
tab
tab
tab
tab
500 mg
850 mg
1000 mg
sr 24hr 500 mg
sr 24hr 750 mg
sr 24hr osmotic 500 mg
sr 24hr osmotic 1000
1
1
1
1
1
1
1
Diabetic Other
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
PROGLYCEM SUS 50MG/ML
2
2
3
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
2
2
2
ST - Step Therapy
PA** - PA Applies if
34
Drug Name
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
TRADJENTA TAB 5MG
Drug Tier Requirements/Limits
3
PA
3
PA
3
PA
Dopamine Receptor Agonists - Antidiabetic
CYCLOSET TAB 0.8MG
3
Incretin Mimetic Agents (GLP Receptor Agonists)
BYDUREON INJ
BYETTA INJ 5MCG
BYETTA INJ 10MCG
VICTOZA INJ 18MG/3ML
2
3
3
3
PA
PA
PA
Insulin
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
HUMALOG INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
2
2
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Insulin Sensitizing Agents
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
pioglitazone hcl tab 15 mg (base equiv)
pioglitazone hcl tab 30 mg (base equiv)
pioglitazone hcl tab 45 mg (base equiv)
3
3
3
1
1
1
Meglitinide Analogues
nateglinide tab 60 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
35
Drug Name
nateglinide tab
repaglinide tab
repaglinide tab
repaglinide tab
120 mg
0.5 mg
1 mg
2 mg
Drug Tier Requirements/Limits
1
1
1
1
Sulfonylureas
chlorpropamide tab 100 mg
chlorpropamide tab 250 mg
glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
glyburide micronized tab 1.5 mg
1
1
1
1
1
1
1
1
1
1
1
glyburide micronized tab 3 mg
1
glyburide micronized tab 6 mg
1
glyburide tab 1.25 mg
1
glyburide tab 2.5 mg
1
glyburide tab 5 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
36
Drug Name
glycron tab 1.5mg
Drug Tier Requirements/Limits
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
2
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
1
1
glycron tab 3mg
GLYCRON TAB 4.5MG
glycron tab 6mg
tolazamide tab 250 mg
tolazamide tab 500 mg
tolbutamide tab 500 mg
ANTIDIARRHEALS
Antiperistaltic Agents
anti-diarrhe tab 2mg
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025
mg
loperamide hcl cap 2 mg
MOTOFEN TAB
1
1
1
1
3
ANTIDOTES
Antidotes - Chelating Agents
CHEMET CAP 100MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG
3
4
4
4
4
PA
PA
PA
PA
1
1
1
1
4
PA
Opioid Antagonists
depade tab 50mg
naloxone hcl inj 0.4 mg/ml
naloxone hcl inj 1 mg/ml
naltrexone hcl tab 50 mg
VIVITROL INJ 380MG
ANTIEMETICS
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
37
Drug Name
Drug Tier Requirements/Limits
5-HT3 Receptor Antagonists
ALOXI INJ
3
ALOXI INJ 0.25MG/5
3
ANZEMET TAB 50MG
3
ANZEMET TAB 100MG
3
granisetron hcl inj 0.1 mg/ml
1
granisetron hcl inj 1 mg/ml
1
granisetron hcl inj 4 mg/4ml (1 mg/ml)
1
granisetron hcl tab 1 mg
1
GRANISOL SOL 2MG/10ML
3
ondansetron hcl and dextrose inj 32
1
mg/50ml
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
1
ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1
ondansetron hcl oral soln 4 mg/5ml
1
ondansetron hcl tab 4 mg
1
ondansetron hcl tab 8 mg
1
ondansetron hcl tab 24 mg
1
ondansetron orally disintegrating tab 4 mg 1
ondansetron orally disintegrating tab 8 mg 1
SANCUSO DIS 3.1MG
3
ZUPLENZ MIS 4MG
3
ZUPLENZ MIS 8MG
3
QL
QL
QL
QL
QL
QL
QL
QL
QL
(1 vial / 15 days)
(1 vial / 15 days)
(3 tabs / 15 days)
(3 tabs / 15 days)
(1 mL / 15 days)
(1 mL / 15 days)
(1 mL / 15 days)
(6 tabs / 15 days)
(30 mL / 15 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
(2 bottles / 15 days)
(12 tabs / 15 days)
(12 tabs / 15 days)
(1 tab / 15 days)
(12 tabs / 15 days)
(12 tabs / 15 days)
(1 patch / 15 days)
(12 tabs / 15 days)
(12 tabs / 15 days)
Antiemetics - Anticholinergic
ANTIVERT TAB 50MG
dimenhydrinate tab 50 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
TRANSDERM-SC DIS 1.5MG
trimethobenzamide hcl cap 300 mg
2
1
1
1
3
1
trimethobenzamide hcl inj 100 mg/ml
1
univert tab 32mg
1
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
Antiemetics - Miscellaneous
CESAMET CAP 1MG
dronabinol cap 2.5 mg
dronabinol cap 5 mg
dronabinol cap 10 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
1
1
1
ST - Step Therapy
QL
QL
QL
QL
(18
(60
(60
(60
caps
caps
caps
caps
/
/
/
/
25
25
25
25
days)
days)
days)
days)
PA** - PA Applies if
38
Drug Name
Drug Tier Requirements/Limits
Substance P/Neurokinin 1 (NK1) Receptor Antagonists
EMEND
EMEND
EMEND
EMEND
CAP
CAP
CAP
PAK
40MG
80MG
125MG
80 & 125
3
3
3
3
QL
QL
QL
QL
(3
(2
(1
(1
caps / 180 days)
caps / 15 days)
cap / 15 days)
pack / 15 days)
ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ERAXIS INJ 50MG
ERAXIS INJ 100MG
MYCAMINE INJ 50MG
MYCAMINE INJ 100MG
3
3
3
3
3
3
Antifungals
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
AMPHOTEC INJ 50MG
AMPHOTEC INJ 100MG
amphotericin b for inj 50 mg
BIO-STATIN CAP 500000
BIO-STATIN CAP 1000000
griseofulvin microsize susp 125 mg/5ml
griseofulvin microsize tab 500 mg
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
LAMISIL GRA 125MG
LAMISIL GRA 187.5MG
nystatin oral powder
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
3
3
3
3
1
2
2
1
1
1
1
3
3
1
1
1
PA
PA
PA
Imidazole-Related Antifungals
fluconazole for susp 10 mg/ml
1
fluconazole for susp 40 mg/ml
1
fluconazole in dextrose inj 200 mg/100ml 1
fluconazole in dextrose inj 400 mg/200ml 1
fluconazole in nacl 0.9% inj 200 mg/100ml 1
fluconazole in nacl 0.9% inj 400 mg/200ml 1
fluconazole tab 50 mg
1
fluconazole tab 100 mg
1
fluconazole tab 150 mg
1
fluconazole tab 200 mg
1
FLUCONAZOLE/ INJ NACL 100
3
itraconazole cap 100 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
39
Drug Name
ketoconazole tab 200 mg
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
SPORANOX SOL 10MG/ML
voriconazole for susp 40 mg/ml
voriconazole tab 50 mg
voriconazole tab 200 mg
Drug Tier Requirements/Limits
1
2
2
2
PA
1
PA
1
PA
1
PA
ANTIHISTAMINES
Antihistamines - Alkylamines
brompheniramine tannate chew tab 12 mg 1
dexchlorpheniramine maleate syrup 2
1
mg/5ml
Antihistamines - Ethanolamines
arbinoxa sol 4mg/5ml
carbinoxamine maleate soln 4 mg/5ml
carbinoxamine maleate tab 4 mg
clemastine fumarate syrup 0.67 mg/5ml
(0.5 mg/5ml base eq)
1
1
1
1
clemastine fumarate tab 2.68 mg
1
diphenhydramine
diphenhydramine
diphenhydramine
diphenhydramine
1
1
1
1
hcl
hcl
hcl
hcl
cap 25 mg
cap 50 mg
elixir 12.5 mg/5ml
inj 50 mg/ml
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
Antihistamines - Non-Sedating
CLARINEX SYP 0.5MG/ML
desloratadine tab 5 mg
desloratadine tab orally disintegrating 2.5
mg
desloratadine tab orally disintegrating 5
mg
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
3
1
1
1
1
1
Antihistamines - Phenothiazines
phenadoz sup 12.5mg
phenadoz sup 25mg
promethazine hcl inj 25 mg/ml
promethazine hcl inj 50 mg/ml
promethazine hcl suppos 12.5 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
40
Drug Name
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
Drug Tier Requirements/Limits
1
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
1
1
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
promethegan sup 12.5mg
promethegan sup 25mg
promethegan sup 50mg
Antihistamines - Piperidines
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
1
1
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Combinations
VYTORIN
VYTORIN
VYTORIN
VYTORIN
TAB
TAB
TAB
TAB
10-10MG
10-20MG
10-40MG
10-80MG
3
3
3
3
ST
ST
ST
ST
3
PA
Antihyperlipidemics - Misc.
LOVAZA CAP 1GM
Bile Acid Sequestrants
cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
prevalite pow 4gm
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
1
1
3
3
ST - Step Therapy
PA** - PA Applies if
41
Drug Name
Drug Tier Requirements/Limits
Fibric Acid Derivatives
choline fenofibrate cap dr 45 mg (fenofibric 1
acid equiv)
choline fenofibrate cap dr 135 mg
1
(fenofibric acid equiv)
fenofibrate micronized cap 43 mg
1
fenofibrate micronized cap 67 mg
1
fenofibrate micronized cap 130 mg
1
fenofibrate micronized cap 134 mg
1
fenofibrate micronized cap 200 mg
1
fenofibrate tab 48 mg
1
fenofibrate tab 54 mg
1
fenofibrate tab 145 mg
1
fenofibrate tab 160 mg
1
fenofibric acid tab 35 mg
1
fenofibric acid tab 105 mg
1
gemfibrozil tab 600 mg
1
HMG CoA Reductase Inhibitors
atorvastatin calcium tab 10 mg
equivalent)
atorvastatin calcium tab 20 mg
equivalent)
atorvastatin calcium tab 40 mg
equivalent)
atorvastatin calcium tab 80 mg
equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
fluvastatin sodium cap 20 mg
fluvastatin sodium cap 40 mg
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
simvastatin tab 5 mg
simvastatin tab 10 mg
simvastatin tab 20 mg
(base
1
(base
1
(base
1
(base
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
3
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
ST
ST
ST
ST
ST
ST
PA** - PA Applies if
42
Drug Name
simvastatin tab 40 mg
simvastatin tab 80 mg
Drug Tier Requirements/Limits
1
1
ST
Intestinal Cholesterol Absorption Inhibitors
ZETIA TAB 10MG
3
ST; PA**
Nicotinic Acid Derivatives
niacin tab cr 500 mg (antihyperlipidemic) 1
niacin tab cr 750 mg (antihyperlipidemic) 1
niacin tab cr 1000 mg (antihyperlipidemic) 1
ANTIHYPERTENSIVES
ACE Inhibitors
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 20 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
perindopril erbumine tab 2 mg
perindopril erbumine tab 4 mg
perindopril erbumine tab 8 mg
quinapril hcl tab 5 mg
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
43
Drug Name
ramipril cap 10 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
Drug Tier Requirements/Limits
1
1
1
1
Agents for Pheochromocytoma
DIBENZYLINE CAP 10MG
3
Angiotensin II Receptor Antagonists
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
candesartan cilexetil tab 4 mg
candesartan cilexetil tab 8 mg
candesartan cilexetil tab 16 mg
candesartan cilexetil tab 32 mg
DIOVAN TAB 40MG
DIOVAN TAB 80MG
DIOVAN TAB 160MG
DIOVAN TAB 320MG
EDARBI TAB 40MG
EDARBI TAB 80MG
eprosartan mesylate tab 600 mg
irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
telmisartan tab 20 mg
telmisartan tab 40 mg
telmisartan tab 80 mg
TEVETEN TAB 400MG
3
3
3
1
1
1
1
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
3
ST
ST
ST
ST;
ST;
ST;
ST;
ST
ST
PA**
PA**
PA**
PA**
ST
Antiadrenergic Antihypertensives
clonidine hcl tab 0.1 mg
1
clonidine hcl tab 0.2 mg
1
clonidine hcl tab 0.3 mg
1
clonidine hcl td patch weekly 0.1 mg/24hr 1
clonidine hcl td patch weekly 0.2 mg/24hr 1
clonidine hcl td patch weekly 0.3 mg/24hr 1
doxazosin mesylate tab 1 mg
1
doxazosin mesylate tab 2 mg
1
doxazosin mesylate tab 4 mg
1
doxazosin mesylate tab 8 mg
1
guanfacine hcl tab 1 mg
1
guanfacine hcl tab 2 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
44
Drug Name
methyldopa tab 250 mg
methyldopa tab 500 mg
methyldopate hcl inj 250 mg/5ml
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
terazosin hcl cap 10 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
Antihypertensive Combinations
amlodipine besylate-benazepril hcl cap 2.5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
20 mg
amlodipine besylate-benazepril hcl cap 5- 1
40 mg
amlodipine besylate-benazepril hcl cap 10- 1
20 mg
amlodipine besylate-benazepril hcl cap 10- 1
40 mg
atenolol & chlorthalidone tab 50-25 mg
1
atenolol & chlorthalidone tab 100-25 mg
1
benazepril & hydrochlorothiazide tab 51
6.25 mg
benazepril & hydrochlorothiazide tab 10- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20-25 1
mg
bisoprolol & hydrochlorothiazide tab 2.5- 1
6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
bisoprolol & hydrochlorothiazide tab 101
6.25 mg
candesartan cilexetil-hydrochlorothiazide 1
tab 16-12.5 mg
candesartan cilexetil-hydrochlorothiazide 1
tab 32-12.5 mg
candesartan cilexetil-hydrochlorothiazide 1
tab 32-25 mg
captopril & hydrochlorothiazide tab 25-15 1
mg
captopril & hydrochlorothiazide tab 25-25 1
mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
45
Drug Name
Drug Tier Requirements/Limits
captopril & hydrochlorothiazide tab 50-15 1
mg
captopril & hydrochlorothiazide tab 50-25 1
mg
enalapril maleate & hydrochlorothiazide tab 1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab 1
10-25 mg
fosinopril sodium & hydrochlorothiazide tab 1
10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 1
20-12.5 mg
irbesartan-hydrochlorothiazide tab 1501
12.5 mg
irbesartan-hydrochlorothiazide tab 3001
12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-25 1
mg
losartan potassium & hydrochlorothiazide 1
tab 50-12.5 mg
losartan potassium & hydrochlorothiazide 1
tab 100-12.5 mg
losartan potassium & hydrochlorothiazide 1
tab 100-25 mg
metoprolol & hydrochlorothiazide tab 50-251
mg
metoprolol & hydrochlorothiazide tab 100- 1
25 mg
metoprolol & hydrochlorothiazide tab 100- 1
50 mg
nadolol & bendroflumethiazide tab 40-5 mg1
nadolol & bendroflumethiazide tab 80-5 mg1
propranolol & hydrochlorothiazide tab 40- 1
25 mg
propranolol & hydrochlorothiazide tab 80- 1
25 mg
quinapril-hydrochlorothiazide tab 10-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-25 mg1
valsartan-hydrochlorothiazide tab 80-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-25 1
mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
46
Drug Name
Drug Tier Requirements/Limits
valsartan-hydrochlorothiazide tab 320-12.5 1
mg
valsartan-hydrochlorothiazide tab 320-25 1
mg
Direct Renin Inhibitors
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
3
3
ST
ST
Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone tab 25 mg
eplerenone tab 50 mg
1
1
Vasodilators
hydralazine hcl inj 20 mg/ml
hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
1
1
1
1
1
1
1
ANTIMALARIALS
Antimalarial Combinations
atovaquone-proguanil hcl tab 62.5-25 mg 1
atovaquone-proguanil hcl tab 250-100 mg 1
COARTEM TAB 20-120MG
3
Antimalarials
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
DARAPRIM TAB 25MG
HALFAN TAB 250MG
hydroxychloroquine sulfate tab 200 mg
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg
quinine sulfate tab 260 mg
1
1
3
3
1
1
3
1
1
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
GUANIDINE TAB 125MG
MESTINON SYP 60MG/5ML
MESTINON TAB TIMESPAN
MYTELASE TAB 10MG
pyridostigmine bromide tab 60 mg
REGONOL INJ 5MG/ML
3
2
3
3
1
3
ANTIMYCOBACTERIAL AGENTS
Anti TB Combinations
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
47
Drug Name
isonarif cap
RIFATER TAB
Drug Tier Requirements/Limits
1
2
Antimycobacterial Agents
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
MYCOBUTIN CAP 150MG
PASER GRA 4GM
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
rifampin for inj 600 mg
TRECATOR TAB 250MG
2
1
1
1
1
1
1
1
3
3
2
1
1
1
1
2
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN TAB 2MG
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
carboplatin iv for inj 150 mg
carboplatin iv soln 50 mg/5ml
carboplatin iv soln 150 mg/15ml
carboplatin iv soln 450 mg/45ml
carboplatin iv soln 600 mg/60ml
cisplatin inj 50 mg/50ml (1 mg/ml)
cisplatin inj 100 mg/100ml (1 mg/ml)
cisplatin inj 200 mg/200ml (1 mg/ml)
CYCLOPHOSPH INJ 1GM
CYCLOPHOSPH INJ 2GM
CYCLOPHOSPH INJ 500MG
cyclophosphamide tab 25 mg
cyclophosphamide tab 50 mg
ELOXATIN INJ 200MG
GLIADEL WAF 7.7MG
HEXALEN CAP 50MG
ifosfamide for inj 1 gm
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
2
2
2
1
1
1
1
1
1
1
1
2
2
2
1
1
2
2
2
1
1
1
ST - Step Therapy
PA** - PA Applies if
48
Drug Name
LEUKERAN TAB 2MG
lomustine cap 10 mg
lomustine cap 40 mg
lomustine cap 100 mg
melphalan hcl for inj 50 mg (base equiv)
MYLERAN TAB 2MG
oxaliplatin for iv inj 50 mg
oxaliplatin for iv inj 100 mg
oxaliplatin iv soln 50 mg/10ml
oxaliplatin iv soln 100 mg/20ml
TEMODAR INJ 100MG
temozolomide cap 5 mg
temozolomide cap 20 mg
temozolomide cap 100 mg
temozolomide cap 140 mg
temozolomide cap 180 mg
temozolomide cap 250 mg
THIOTEPA INJ 15MG
ZANOSAR INJ 1GM
Drug Tier Requirements/Limits
2
1
1
1
1
2
1
1
1
1
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
2
2
Antimetabolites
adrucil inj 500/10ml
ALIMTA INJ 100MG
ALIMTA INJ 500MG
ARRANON INJ 5MG/ML
azacitidine for inj 100 mg
capecitabine tab 150 mg
capecitabine tab 500 mg
cladribine inj 1 mg/ml
CLOLAR INJ 1MG/ML
cytarabine for inj 1 gm
cytarabine for inj 100 mg
cytarabine for inj 500 mg
cytarabine inj 20 mg/ml
cytarabine inj pf 20 mg/ml
cytarabine inj pf 100 mg/ml
decitabine for inj 50 mg
DEPOCYT INJ 50MG/5ML
floxuridine for inj 0.5 gm
fludarabine phosphate for inj 50 mg
fludarabine phosphate inj 25 mg/ml
fluorouracil inj 1 gm/20ml (50 mg/ml)
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
fluorouracil inj 5 gm/100ml (50 mg/ml)
fluorouracil inj 500 mg/10ml (50 mg/ml)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
2
2
2
4
4
4
1
2
1
1
1
1
1
1
4
2
1
1
1
1
1
1
1
ST - Step Therapy
PA
PA
PA
PA
PA** - PA Applies if
49
Drug Name
gemcitabine hcl for inj 1 gm
gemcitabine hcl for inj 2 gm
gemcitabine hcl for inj 200 mg
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj 25 mg/ml
methotrexate sodium inj pf 25 mg/ml
methotrexate sodium tab 2.5 mg (base
equiv)
TABLOID TAB 40MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
TREXALL TAB 10MG
TREXALL TAB 15MG
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
2
3
3
3
3
Antineoplastic - Angiogenesis Inhibitors
ZALTRAP INJ 100/4ML
ZALTRAP INJ 200/8ML
4
4
PA
PA
4
4
2
4
4
4
4
4
4
PA
PA
Antineoplastic - Antibodies
ARZERRA CON 100/5ML
ARZERRA CON 1000/50
CAMPATH INJ 30MG/ML
ERBITUX INJ 100MG
ERBITUX INJ 200MG
GAZYVA INJ 25MG/ML
RITUXAN INJ 100MG
YERVOY INJ 50MG
YERVOY INJ 200MG
PA
PA
PA
PA
PA
PA
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAP 150MG
4
PA
Antineoplastic - Hormonal and Related Agents
anastrozole tab 1 mg
bicalutamide tab 50 mg
DEPO-PROVERA INJ 400/ML
ELIGARD INJ 7.5MG
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
ELIGARD INJ 45MG
EMCYT CAP 140MG
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
FIRMAGON INJ 80MG
FIRMAGON INJ 120MG
flutamide cap 125 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
3
4
4
4
4
2
1
2
2
4
4
1
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
50
Drug Name
letrozole tab 2.5 mg
leuprolide acetate inj kit 5 mg/ml
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 7.5MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LYSODREN TAB 500MG
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
NILANDRON TAB 150MG
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
TRELSTAR MIX INJ 22.5MG
XTANDI CAP 40MG
ZYTIGA TAB 250MG
Drug Tier Requirements/Limits
1
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
2
1
1
1
2
1
1
4
4
4
4
4
PA
PA
PA
PA
PA
Antineoplastic Antibiotics
adriamycin inj 10mg
ADRIAMYCIN INJ 20MG
bleomycin sulfate for inj 15 unit
bleomycin sulfate for inj 30 unit
dactinomycin for inj 0.5 mg
daunorubicin hcl for inj 20 mg
daunorubicin hcl inj 5 mg/ml (base equiv)
DAUNOXOME INJ 2MG/ML
doxorubicin hcl for inj 10 mg
doxorubicin hcl for inj 50 mg
doxorubicin hcl inj 2 mg/ml
epirubicin hcl inj 10 mg/5ml (2 mg/ml)
epirubicin hcl inj 50 mg/25ml (2 mg/ml)
epirubicin hcl inj 150 mg/75ml (2 mg/ml)
epirubicin hcl inj 200 mg/100ml (2 mg/ml)
EPIRUBICIN INJ 50MG
EPIRUBICIN INJ 200MG
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)
lipodox 50 inj 2mg/ml
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
2
2
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
51
Drug Name
Drug Tier Requirements/Limits
lipodox inj 2mg/ml
1
mitomycin for inj 5 mg
1
mitomycin for inj 20 mg
1
mitomycin for inj 40 mg
1
mitoxantrone hcl inj conc 20 mg/10ml (2 4
PA
mg/ml)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 4
PA
mg/ml)
mitoxantrone hcl inj conc 30 mg/15ml (2 4
PA
mg/ml)
Antineoplastic Combinations
ifosfamide & mesna inj kit 1000-1000 mg
1
Antineoplastic Enzyme Inhibitors
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
52
Drug Name
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TORISEL SOL 25MG/ML
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZOLINZA CAP 100MG
Drug Tier Requirements/Limits
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
Antineoplastic Enzymes
ELSPAR INJ 10000UNT
ONCASPAR INJ 750/ML
4
4
PA
Antineoplastic Radiopharmaceuticals
QUADRAMET INJ
2
Antineoplastics - Immunomodulators
POMALYST
POMALYST
POMALYST
POMALYST
CAP
CAP
CAP
CAP
1MG
2MG
3MG
4MG
4
4
4
4
PA
PA
PA
PA
4
4
1
1
1
4
4
4
4
4
4
4
2
PA
PA
Antineoplastics Misc.
ACTIMMUNE INJ 2MU/0.5
ALFERON N INJ 5MU/ML
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
hydroxyurea cap 500 mg
INTRON-A INJ 3MU PEN
INTRON-A INJ 5MU PEN
INTRON-A INJ 10MU
INTRON-A INJ 10MU PEN
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
MATULANE CAP 50MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
53
Drug Name
ONTAK INJ 150/ML
pentostatin for inj 10 mg
PHOTOFRIN INJ 75MG
SYNRIBO INJ 3.5MG
TARGRETIN CAP 75MG
THERACYS INJ
TICE BCG INJ
tretinoin cap 10 mg
TRISENOX SOL 10MG/10M
UVADEX INJ 20MCG/ML
Drug Tier Requirements/Limits
2
1
2
4
PA
4
PA
2
2
1
2
2
Chemotherapy Adjuncts
KEPIVANCE INJ 6.25MG
2
Chemotherapy Rescue/Antidote Agents
amifostine crystalline for inj 500 mg
dexrazoxane for inj 250 mg
dexrazoxane for inj 500 mg
leucovorin calcium for inj 50 mg
leucovorin calcium for inj 100 mg
leucovorin calcium for inj 200 mg
leucovorin calcium for inj 350 mg
leucovorin calcium inj 10 mg/ml
leucovorin calcium tab 5 mg
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
LEUCOVORIN INJ CALCIUM
mesna inj 100 mg/ml
MESNEX TAB 400MG
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
Mitotic Inhibitors
ABRAXANE INJ 100MG
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
docetaxel for inj conc 20 mg/ml
docetaxel for inj conc 80 mg/4ml (20
mg/ml)
DOCETAXEL INJ 20/0.5ML
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 80MG/2ML
DOCETAXEL INJ 80MG/8ML
DOCETAXEL INJ 160/16ML
ETOPOPHOS INJ 100MG
etoposide cap 50 mg
etoposide inj 100mg/5ml (20 mg/ml)
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
2
2
2
1
1
2
2
2
2
2
2
1
1
1
ST - Step Therapy
PA** - PA Applies if
54
Drug Name
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml)
paclitaxel iv conc 150 mg/25ml (6 mg/ml)
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
TAXOTERE INJ 20/0.5ML
TAXOTERE INJ 80MG/2ML
toposar inj 20mg/ml
toposar inj 100/5ml
VINBLASTINE INJ 10MG
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
vinorelbine tartrate inj 10 mg/ml
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml)
VUMON INJ 50MG/5ML
Drug Tier Requirements/Limits
1
1
1
2
2
1
1
2
1
1
1
1
1
2
Topoisomerase I Inhibitors
CAMPTOSAR INJ 300/15ML
2
HYCAMTIN CAP 0.25MG
4
HYCAMTIN CAP 1MG
4
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
1
irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1
irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1
topotecan hcl for inj 4 mg
1
TOPOTECAN INJ 4MG/4ML
2
PA
PA
ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
carbidopa tab 25 mg
1
Antiparkinson Anticholinergics
benztropine mesylate inj 1 mg/ml
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
1
1
1
1
1
1
1
Antiparkinson COMT Inhibitors
entacapone tab 200 mg
TASMAR TAB 100MG
1
3
Antiparkinson Dopaminergics
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
4
ST - Step Therapy
PA
PA** - PA Applies if
55
Drug Name
Drug Tier Requirements/Limits
bromocriptine mesylate cap 5 mg
1
bromocriptine mesylate tab 2.5 mg
1
carbidopa & levodopa orally disintegrating 1
tab 10-100 mg
carbidopa & levodopa orally disintegrating 1
tab 25-100 mg
carbidopa & levodopa orally disintegrating 1
tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
1
carbidopa & levodopa tab 25-100 mg
1
carbidopa & levodopa tab 25-250 mg
1
carbidopa & levodopa tab cr 25-100 mg
1
carbidopa & levodopa tab cr 50-200 mg
1
carbidopa-levodopa-entacapone tabs 12.5- 1
50-200 mg
carbidopa-levodopa-entacapone tabs
1
18.75-75-200 mg
carbidopa-levodopa-entacapone tabs 25- 1
100-200 mg
carbidopa-levodopa-entacapone tabs
1
31.25-125-200 mg
carbidopa-levodopa-entacapone tabs 37.5- 1
150-200 mg
carbidopa-levodopa-entacapone tabs 50- 1
200-200 mg
MIRAPEX ER TAB 0.75MG
2
MIRAPEX ER TAB 0.375MG
2
MIRAPEX ER TAB 1.5MG
2
MIRAPEX ER TAB 2.25MG
2
MIRAPEX ER TAB 3.75MG
2
MIRAPEX ER TAB 3MG
2
MIRAPEX ER TAB 4.5MG
2
pramipexole dihydrochloride tab 0.5 mg
1
pramipexole dihydrochloride tab 0.25 mg 1
pramipexole dihydrochloride tab 0.75 mg 1
pramipexole dihydrochloride tab 0.125 mg 1
pramipexole dihydrochloride tab 1 mg
1
pramipexole dihydrochloride tab 1.5 mg
1
ropinirole hydrochloride tab 0.5 mg
1
ropinirole hydrochloride tab 0.25 mg
1
ropinirole hydrochloride tab 1 mg
1
ropinirole hydrochloride tab 2 mg
1
ropinirole hydrochloride tab 3 mg
1
ropinirole hydrochloride tab 4 mg
1
ropinirole hydrochloride tab 5 mg
1
Antiparkinson Monoamine Oxidase Inhibitors
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
56
Drug Name
AZILECT TAB 0.5MG
AZILECT TAB 1MG
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
ZELAPAR TAB 1.25MG
Drug Tier Requirements/Limits
2
2
1
1
3
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
lithium carbonate tab cr 450 mg
LITHIUM CITR SOL 8MEQ/5ML
1
1
1
1
1
1
3
Antipsychotics - Misc.
GEODON INJ 20MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
ziprasidone hcl cap 20
ziprasidone hcl cap 40
ziprasidone hcl cap 60
ziprasidone hcl cap 80
mg
mg
mg
mg
3
2
2
2
2
2
1
1
1
1
ST
ST
ST
ST
ST
Benzisoxazoles
FANAPT
FANAPT
FANAPT
FANAPT
FANAPT
FANAPT
FANAPT
FANAPT
INVEGA
INVEGA
INVEGA
INVEGA
INVEGA
INVEGA
INVEGA
INVEGA
INVEGA
PAK
TAB 1MG
TAB 2MG
TAB 4MG
TAB 6MG
TAB 8MG
TAB 10MG
TAB 12MG
SUST INJ 39/0.25
SUST INJ 78/0.5ML
SUST INJ 117/0.75
SUST INJ 156MG/ML
SUST INJ 234/1.5
TAB 1.5MG
TAB 3MG
TAB 6MG
TAB 9MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
ST - Step Therapy
ST
ST
ST
ST
ST
ST
ST
ST
PA
PA
PA
PA
PA
ST
ST
ST
ST
PA** - PA Applies if
57
Drug Name
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone orally disintegrating
risperidone orally disintegrating
mg
risperidone orally disintegrating
risperidone orally disintegrating
risperidone orally disintegrating
risperidone orally disintegrating
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
risperidone tab 2 mg
risperidone tab 3 mg
risperidone tab 4 mg
Drug Tier Requirements/Limits
2
PA
2
PA
2
PA
2
PA
tab 0.5 mg 1
tab 0.25 1
tab
tab
tab
tab
1
2
3
4
mg
mg
mg
mg
1
1
1
1
1
1
1
1
1
1
1
decanoate im soln 50 mg/ml
decanoate im soln 100 mg/ml
lactate inj 5 mg/ml
lactate oral conc 2 mg/ml
tab 0.5 mg
tab 1 mg
tab 2 mg
tab 5 mg
tab 10 mg
tab 20 mg
1
1
1
1
1
1
1
1
1
1
Butyrophenones
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
Dibenzapines
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
olanzapine for im inj 10 mg
olanzapine orally disintegrating
olanzapine orally disintegrating
olanzapine orally disintegrating
olanzapine orally disintegrating
olanzapine tab 2.5 mg
1
1
1
1
1
1
1
1
1
tab 5 mg 1
tab 10 mg 1
tab 15 mg 1
tab 20 mg 1
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
58
Drug Name
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
3
ST
3
ST
2
ST; PA**
2
ST; PA**
2
ST; PA**
2
ST; PA**
2
ST; PA**
Phenothiazines
CHLORPROMAZ INJ 25MG/ML
chlorpromazine hcl tab 10 mg
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
compro sup 25mg
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
prochlorperazine edisylate inj 5 mg/ml
prochlorperazine maleate tab 5 mg
prochlorperazine maleate tab 10 mg
prochlorperazine suppos 25 mg
thioridazine hcl tab 10 mg
thioridazine hcl tab 25 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
59
Drug Name
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
trifluoperazine hcl tab 10 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
Quinolinone Derivatives
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
DISC TAB 10MG
DISC TAB 15MG
INJ 9.75MG
SOL 1MG/ML
TAB 2MG
TAB 5MG
TAB 10MG
TAB 15MG
TAB 20MG
TAB 30MG
2
2
2
2
2
2
2
2
2
2
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Thioxanthenes
NAVANE CAP 20MG
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
3
1
1
1
1
ANTISEPTICS DISINFECTANTS
Chlorine Antiseptics
PHISOHEX LIQ 3%
3
ANTIVIRALS
Antiretrovirals
abacavir sulfate tab 300 mg (base equiv) 1
abacavir sulfate-lamivudine-zidovudine tab 1
300-150-300 mg
APTIVUS CAP 250MG
2
APTIVUS SOL
2
ATRIPLA TAB
2
COMPLERA TAB
2
CRIXIVAN CAP 100MG
2
CRIXIVAN CAP 200MG
2
CRIXIVAN CAP 400MG
2
didanosine delayed release capsule 125 mg1
didanosine delayed release capsule 200 mg1
didanosine delayed release capsule 250 mg1
didanosine delayed release capsule 400 mg1
EDURANT TAB 25MG
2
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
60
Drug Name
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EPIVIR HBV SOL 5MG/ML
EPIVIR SOL 10MG/ML
EPZICOM TAB 600-300
FUZEON INJ 90MG
FUZEON KIT
INTELENCE TAB 25MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ISENTRESS CHW 25MG
ISENTRESS CHW 100MG
ISENTRESS TAB 400MG
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine tab 100 mg
lamivudine tab 150 mg
lamivudine tab 300 mg
lamivudine-zidovudine tab 150-300 mg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
nevirapine susp 50 mg/5ml
nevirapine tab 200 mg
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
RETROVIR INJ 10MG/ML
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
2
2
2
2
2
4
PA
4
PA
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
ST - Step Therapy
PA** - PA Applies if
61
Drug Name
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
STRIBILD TAB
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TRUVADA TAB 200-300
VIDEX SOL 2GM
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
VIRAMUNE XR TAB 400MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
Drug Tier Requirements/Limits
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
CMV Agents
cidofovir iv inj 75 mg/ml
foscarnet sodium inj 24 mg/ml
ganciclovir cap 250 mg
ganciclovir cap 500 mg
VALCYTE SOL 50MG/ML
VALCYTE TAB 450MG
1
1
1
1
3
3
Hepatitis Agents
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
INCIVEK TAB 375MG
INFERGEN INJ 9MCG
INFERGEN INJ 15MCG
OLYSIO CAP 150MG
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
2
2
2
4
4
4
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
62
Drug Name
PEG-INTRON KIT 80MCG RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150 RP
PEG-INTRON KIT 150MCG
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGASYS KIT
REBETOL SOL 40MG/ML
ribasphere cap 200mg
ribasphere tab 200mg
ribasphere tab 400mg
ribasphere tab 600mg
ribavirin cap 200 mg
ribavirin tab 200 mg
SOVALDI TAB 400MG
TYZEKA TAB 600MG
VICTRELIS CAP 200MG
Drug Tier Requirements/Limits
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
Herpes Agents
acyclovir cap 200 mg
acyclovir sodium for inj 500 mg
acyclovir sodium for inj 1000 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
1
1
1
1
1
1
1
1
1
1
1
Influenza Agents
RELENZA MIS DISKHALE
2
rimantadine hydrochloride tab 100 mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
TAMIFLU SUS 12MG/ML
1
2
2
2
2
2
QL (2 inhalers / 180
days)
QL
QL
QL
QL
QL
(28 caps / 180 days)
(14 caps / 180 days)
(14 caps / 180 days)
(180 mL / 180 days)
(180 mL / 180 days)
Respiratory Syncytial Virus (RSV) Agents
VIRAZOLE INH 6GM
3
ASSORTED CLASSES
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
63
Drug Name
Drug Tier Requirements/Limits
Chelating Agents
DEPEN TITRA TAB 250MG
SYPRINE CAP 250MG
3
3
Immunomodulators
REVLIMID CAP 2.5MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
THALOMID CAP 50MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
4
4
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Immunosuppressive Agents
ATGAM INJ 250MG
AZASAN TAB 75 MG
AZASAN TAB 100MG
azathioprine sodium for inj 100 mg
azathioprine tab 50 mg
CELLCEPT IV INJ 500MG
CELLCEPT SUS 200MG/ML
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine iv soln 50 mg/ml
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified cap 100 mg
cyclosporine modified oral soln 100 mg/ml
gengraf cap 25mg
gengraf cap 100mg
gengraf sol 100mg/ml
mycophenolate mofetil cap 250 mg
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)
NULOJIX INJ 250MG
ORTHOCLONE INJ OKT3
PROGRAF INJ 5MG/ML
RAPAMUNE SOL 1MG/ML
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
1
1
3
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
2
2
2
ST - Step Therapy
PA** - PA Applies if
64
Drug Name
SANDIMMUNE SOL 100MG/ML
SIMULECT INJ 10MG
SIMULECT INJ 20MG
sirolimus tab 0.5 mg
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
THYMOGLOBULN INJ 25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Tier Requirements/Limits
3
3
3
1
1
1
1
3
2
2
2
Irrigation Solutions
physiolyte sol
physiosol sol irrigat
tis-u-sol sol
1
1
1
Potassium Removing Resins
kionex sus 15gm/60
1
sodium polystyrene sulfonate oral susp 15 1
gm/60ml
sodium polystyrene sulfonate rectal susp 1
30 gm/120ml
Systemic Lupus Erythematosus Agents
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
4
4
PA
PA
BETA BLOCKERS
Alpha-Beta Blockers
carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
carvedilol tab 12.5 mg
carvedilol tab 25 mg
COREG CR CAP 10MG
COREG CR CAP 20MG
COREG CR CAP 40MG
COREG CR CAP 80MG
labetalol hcl iv soln 5 mg/ml
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
1
1
1
1
3
3
3
3
1
1
1
1
Beta Blockers Cardio-Selective
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
65
Drug Name
betaxolol hcl tab 10 mg
betaxolol hcl tab 20 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
metoprolol succinate tab sr 24hr
metoprolol succinate tab sr 24hr
metoprolol succinate tab sr 24hr
metoprolol succinate tab sr 24hr
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 mg
25 mg
50 mg
100 mg
200 mg
Drug Tier Requirements/Limits
1
1
1
1
3
3
3
3
1
1
1
1
1
1
1
1
Beta Blockers Non-Selective
LEVATOL TAB 20MG
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
nadolol tab 160 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap sr 24hr 60 mg
propranolol hcl cap sr 24hr 80 mg
propranolol hcl cap sr 24hr 120 mg
propranolol hcl cap sr 24hr 160 mg
propranolol hcl inj 1 mg/ml
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
sorine tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl (afib/afl) tab 160 mg
SOTALOL HCL INJ 150/10ML
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
ST - Step Therapy
PA** - PA Applies if
66
Drug Name
sotalol hcl tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
timolol maleate tab 5 mg
timolol maleate tab 10 mg
timolol maleate tab 20 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
BIOLOGICALS MISC
Biologicals Misc
ADAGEN INJ 250/ML
4
PA
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
afeditab tab 30mg cr
afeditab tab 60mg cr
amlodipine besylate tab 2.5 mg
amlodipine besylate tab 5 mg
amlodipine besylate tab 10 mg
CARDENE IV INJ 40/200ML
CARDENE IV SOL 20/200ML
CARDIZEM LA TAB 120MG
cartia xt cap 120/24hr
cartia xt cap 180/24hr
cartia xt cap 240/24hr
cartia xt cap 300/24hr
dilt-cd cap 120mg
dilt-cd cap 180mg
dilt-cd cap 240mg
dilt-cd cap 300mg
diltiazem hcl cap sr 12hr 60 mg
diltiazem hcl cap sr 12hr 90 mg
diltiazem hcl cap sr 12hr 120 mg
diltiazem hcl cap sr 24hr 120 mg
diltiazem hcl cap sr 24hr 180 mg
diltiazem hcl cap sr 24hr 240 mg
diltiazem hcl coated beads cap sr
mg
diltiazem hcl coated beads cap sr
mg
diltiazem hcl coated beads cap sr
mg
diltiazem hcl coated beads cap sr
mg
diltiazem hcl coated beads cap sr
mg
1
1
1
1
1
3
3
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
24hr 120 1
24hr 180 1
24hr 240 1
24hr 300 1
24hr 360 1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
67
Drug Name
Drug Tier Requirements/Limits
diltiazem hcl extended release beads cap sr1
24hr 120 mg
diltiazem hcl extended release beads cap sr1
24hr 180 mg
diltiazem hcl extended release beads cap sr1
24hr 240 mg
diltiazem hcl extended release beads cap sr1
24hr 300 mg
diltiazem hcl extended release beads cap sr1
24hr 360 mg
diltiazem hcl extended release beads cap sr1
24hr 420 mg
diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 1
diltiazem hcl iv soln 50 mg/10ml (5
1
mg/ml)
diltiazem hcl iv soln 125 mg/25ml (5
1
mg/ml)
diltiazem hcl tab 30 mg
1
diltiazem hcl tab 60 mg
1
diltiazem hcl tab 90 mg
1
diltiazem hcl tab 120 mg
1
DILTIAZEM INJ 100MG
3
diltzac cap 120mg/24
1
diltzac cap 180mg/24
1
diltzac cap 240mg/24
1
diltzac cap 300mg/24
1
diltzac cap 360mg/24
1
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
1
felodipine tab sr 24hr 10 mg
1
isradipine cap 2.5 mg
1
isradipine cap 5 mg
1
matzim la tab 180mg/24
1
matzim la tab 240mg/24
1
matzim la tab 300mg/24
1
matzim la tab 360mg/24
1
matzim la tab 420mg/24
1
nicardipine hcl cap 20 mg
1
nicardipine hcl cap 30 mg
1
nicardipine hcl iv soln 2.5 mg/ml
1
nifediac cc tab 30mg er
1
nifediac cc tab 60mg er
1
nifediac cc tab 90mg er
1
nifedical xl tab 30mg
1
nifedical xl tab 60mg
1
nifedipine tab sr 24hr 30 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
68
Drug Name
nifedipine tab sr 24hr 60 mg
nifedipine tab sr 24hr 90 mg
nifedipine tab sr 24hr osmotic 30 mg
nifedipine tab sr 24hr osmotic 60 mg
nifedipine tab sr 24hr osmotic 90 mg
nimodipine cap 30 mg
nisoldipine tab sr 24hr 8.5 mg
nisoldipine tab sr 24hr 17 mg
nisoldipine tab sr 24hr 20 mg
nisoldipine tab sr 24hr 25.5 mg
nisoldipine tab sr 24hr 30 mg
nisoldipine tab sr 24hr 34 mg
nisoldipine tab sr 24hr 40 mg
taztia xt cap 120mg/24
taztia xt cap 180mg/24
taztia xt cap 240mg/24
taztia xt cap 300mg/24
taztia xt cap 360mg/24
verapamil hcl cap sr 24hr 100 mg
verapamil hcl cap sr 24hr 120 mg
verapamil hcl cap sr 24hr 180 mg
verapamil hcl cap sr 24hr 200 mg
verapamil hcl cap sr 24hr 240 mg
verapamil hcl cap sr 24hr 300 mg
verapamil hcl cap sr 24hr 360 mg
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab 120 mg
verapamil hcl tab cr 120 mg
verapamil hcl tab cr 180 mg
verapamil hcl tab cr 240 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CARDIOTONICS
Cardiac Glycosides
digox tab 0.25mg
digox tab 0.125mg
digoxin inj 0.25 mg/ml
digoxin oral soln 0.05 mg/ml
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
LANOXIN PED INJ 0.1MG/ML
LANOXIN TAB 0.0625MG
LANOXIN TAB 0.1875MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
3
2
2
ST - Step Therapy
PA** - PA Applies if
69
Drug Name
Drug Tier Requirements/Limits
CARDIOVASCULAR AGENTS - MISC.
Impotence Agents
CIALIS TAB 2.5MG
3
PA
4
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
PA
PA
Prostaglandin Vasodilators
epoprostenol sodium for inj 0.5 mg
epoprostenol sodium for inj 1.5 mg
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
REMODULIN INJ 10MG/ML
TYVASO START SOL 0.6MG/ML
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
Pulmonary Hypertension - Endothelin Receptor Antagonists
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
TRACLEER TAB 62.5MG
TRACLEER TAB 125MG
4
4
4
4
PA
PA
PA
PA
Pulmonary Hypertension - Phosphodiesterase Inhibitors
ADCIRCA TAB 20MG
REVATIO INJ
sildenafil citrate tab 20 mg
4
4
4
PA
PA
PA
CEPHALOSPORINS
Cephalosporins - 1st Generation
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
CEFAZOL/DEX SOL 1GM
CEFAZOL/DEX SOL 2GM
CEFAZOLIN INJ 1GM/50ML
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 10 gm
cefazolin sodium for inj 20 gm
cefazolin sodium for inj 500 mg
cefazolin sodium for iv soln 1 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin cap 750 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
cephalexin tab 250 mg
cephalexin tab 500 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
70
Drug Name
Drug Tier Requirements/Limits
Cephalosporins - 2nd Generation
cefaclor cap 250 mg
cefaclor cap 500 mg
CEFACLOR ER TAB 500MG
cefaclor for susp 125 mg/5ml
cefaclor for susp 250 mg/5ml
cefaclor for susp 375 mg/5ml
CEFOTET/DEX INJ 1-3.58%
CEFOTET/DEX INJ 2-2.08%
CEFOTETAN INJ 1GM/10ML
CEFOTETAN INJ 2GM/20ML
CEFOTETAN INJ 10G
CEFOXITIN INJ 1GM
CEFOXITIN INJ 2GM
cefoxitin sodium for inj 1 gm
cefoxitin sodium for inj 2 gm
cefoxitin sodium for inj 10 gm
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
CEFTIN SUS 250/5ML
CEFUROX/DEXT INJ 1.5GM
CEFUROX/DEXT INJ 750MG
cefuroxime axetil for susp 125 mg/5ml
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
CEFUROXIME INJ 7.5GM
CEFUROXIME INJ 75GM
CEFUROXIME INJ 225GM
cefuroxime sodium for inj 1.5 gm
cefuroxime sodium for inj 7.5 gm
cefuroxime sodium for inj 750 mg
cefuroxime sodium for iv soln 1.5 gm
MEFOXIN INJ 1GM/50ML
MEFOXIN INJ 2GM/50ML
ZINACEF INJ 750MG
ZINACEF/H20 INJ 1.5GM PB
1
1
2
1
1
1
3
3
3
3
3
3
3
1
1
1
1
1
1
1
2
3
3
1
1
1
3
3
3
1
1
1
1
3
3
3
3
Cephalosporins - 3rd Generation
CEDAX SUS 90MG/5ML
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
1
1
1
ST - Step Therapy
PA** - PA Applies if
71
Drug Name
cefditoren pivoxil tab 200 mg (base
equivalent)
cefditoren pivoxil tab 400 mg (base
equivalent)
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 10 gm
cefotaxime sodium for inj 500 mg
cefpodoxime proxetil for susp 50 mg/5ml
cefpodoxime proxetil for susp 100 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
ceftazidime for inj 1 gm
ceftazidime for inj 2 gm
ceftazidime for inj 6 gm
ceftazidime for inj 500 mg
CEFTAZIDIME INJ 100GM
CEFTAZIDIME/ SOL D5W 1GM
CEFTAZIDIME/ SOL D5W 2GM
ceftibuten cap 400 mg
ceftibuten for susp 180 mg/5ml
CEFTRIAXONE INJ 100GM
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 2 gm
ceftriaxone sodium for inj 10 gm
ceftriaxone sodium for inj 250 mg
ceftriaxone sodium for inj 500 mg
ceftriaxone sodium for iv soln 1 gm
ceftriaxone sodium for iv soln 2 gm
CLAFORAN INJ 1GM
CLAFORAN INJ 2GM
FORTAZ INJ 1GM
FORTAZ INJ 2GM
SUPRAX CAP 400MG
SUPRAX CHW 100MG
SUPRAX CHW 200MG
SUPRAX SUS 100/5ML
SUPRAX SUS 200/5ML
SUPRAX SUS 500/5ML
SUPRAX TAB 400MG
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
1
1
3
1
1
1
1
1
1
1
3
3
3
3
2
2
2
2
2
2
2
1
1
1
Cephalosporins - 4th Generation
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
72
Drug Name
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
CEFEPIME INJ 1GM
CEFEPIME INJ 2GM
MAXIPIME INJ 1GM
MAXIPIME INJ 2GM
Drug Tier Requirements/Limits
1
1
3
3
3
3
Cephalosporins - 5th Generation
TEFLARO INJ 400MG
TEFLARO INJ 600MG
3
3
CONTRACEPTIVES
Combination Contraceptives - Oral
altavera tab
alyacen tab 1/35
alyacen tab 7/7/7
amethia tab
amethyst tab 90-20mcg
apri tab
aranelle tab
aviane tab
azurette tab 28 day
BEYAZ TAB
caziant pak
cesia pak
chateal tab 0.15/30
cryselle-28 tab 28 tabs
cyclafem tab 1/35
cyclafem tab 7/7/7
dasetta tab 1/35
dasetta tab 7/7/7
drospirenone-ethinyl estradiol tab 3-0.03
mg
elinest tab
emoquette tab
enpresse-28 tab
falmina tab
GENERESS FE CHW
gianvi tab 3-0.02mg
gildess fe tab 1.5/30
gildess fe tab 1/20
gildess tab 1.5/30
gildess tab 1/20
introvale tab
jolessa tab
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ST - Step Therapy
PA** - PA Applies if
73
Drug Name
Drug Tier Requirements/Limits
junel 1.5/30 tab
0
junel 1/20 tab
0
junel fe tab 1.5/30
0
junel fe tab 1/20
0
kariva tab 28 day
0
kelnor tab 1/35
0
kurvelo tab 0.15/30
0
leena tab
0
lessina tab
0
levonest tab
0
levonorg-eth est tab 0.1-0.02mg(84) & eth 0
est tab 0.01mg(7)
levonorgestrel & ethinyl estradiol (91-day) 0
tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol tab 0.15 0
mg-30 mcg
levora-28 tab 0.15/30
0
LO LOESTRIN TAB
0
LO MINASTRIN PAK FE
0
lomedia 24 tab fe
0
loryna tab 3-0.02mg
0
low-ogestrel tab
0
lutera tab
0
marlissa tab 0.15/30
0
microgestin tab 1.5/30
0
microgestin tab 1/20
0
microgestin tab fe1.5/30
0
microgestin tab fe 1/20
0
MINASTRIN 24 CHW FE
0
mono-linyah tab 0.25-35
0
mononessa tab
0
myzilra tab
0
NATAZIA TAB
0
necon tab 0.5/35
0
necon tab 1/35
0
necon tab 1/50-28
0
necon tab 7/7/7
0
NECON TAB 10/11-28
0
norgestimate & ethinyl estradiol tab 0.25 0
mg-35 mcg
norgestimate-eth estrad tab 0.180
35/0.215-35/0.25-35 mg-mcg
norgestrel & ethinyl estradiol tab 0.3 mg- 0
30 mcg
nortrel tab 0.5/35
0
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
74
Drug Name
nortrel tab 1/35
nortrel tab 7/7/7
ocella tab 3-0.03mg
ogestrel tab
orsythia tab
ORTHO TRI- TAB CYCLN LO
OVCON 50 TAB 28
portia-28 tab
previfem tab
QUARTETTE TAB
quasense tab
reclipsen tab
SAFYRAL TAB
solia tab
sprintec 28 tab 28 day
sronyx tab
syeda tab 3-0.03mg
tilia fe tab
tri-linyah tab
tri-lo- tab sprintec
tri-previfem tab
tri-sprintec tab
trinessa tab
trivora-28 tab
velivet pak
vestura tab 3-0.02mg
viorele tab
wera tab 0.5/35
zarah tab 3-0.03mg
zenchent tab
zeosa chw
zovia 1/35e tab
zovia 1/50e tab
Drug Tier Requirements/Limits
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Combination Contraceptives - Transdermal
ORTHO EVRA DIS WEEK
0
Combination Contraceptives - Vaginal
NUVARING MIS
0
QL (13 / 300 days)
Emergency Contraceptives
ELLA TAB 30MG
levonorgestrel tab 0.75 mg
next choice tab 0.75mg
next choice tab 1.5mg
0
0
0
0
Progestin Contraceptives - IUD
MIRENA IUD SYSTEM
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
0
ST - Step Therapy
QL (1 / 300 days)
PA** - PA Applies if
75
Drug Name
SKYLA IUD 13.5MG
Drug Tier Requirements/Limits
0
QL (1 / 300 days)
Progestin Contraceptives - Implants
IMPLANON IMP 68MG
NEXPLANON IMP 68MG
0
0
QL (1 / 300 days)
QL (1 / 300 days)
Progestin Contraceptives - Injectable
DEPO-SQ PROV INJ 104
0
medroxyprogesterone acetate im susp 150 0
mg/ml
QL (1 inj / 75 days)
QL (1 inj / 75 days)
Progestin Contraceptives - Oral
camila tab 0.35mg
errin tab 0.35mg
heather tab 0.35mg
jolivette tab 0.35mg
nora-be tab 0.35mg
norethindrone tab 0.35 mg
0
0
0
0
0
0
CORTICOSTEROIDS
Glucocorticosteroids
a-hydrocort inj 100mg
1
a-methapred inj 40mg
1
a-methapred inj 125mg
1
asmalpred sol plus
1
baycadron elx 0.5/5ml
1
budesonide cap sr 24hr 3 mg
1
cortisone acetate tab 25 mg
1
DEPO-MEDROL INJ 20MG/ML
3
DEXAMETHASON CON 1MG/ML
2
dexamethasone elixir 0.5 mg/5ml
1
dexamethasone sod phosphate
1
preservative free inj 10 mg/ml
dexamethasone sodium phosphate inj 20 1
mg/5ml
dexamethasone sodium phosphate inj 100 1
mg/10ml
dexamethasone soln 0.5 mg/5ml
1
dexamethasone tab 0.5 mg
1
dexamethasone tab 0.75 mg
1
dexamethasone tab 1 mg
1
dexamethasone tab 1.5 mg
1
dexamethasone tab 2 mg
1
dexamethasone tab 4 mg
1
dexamethasone tab 6 mg
1
DEXPAK PAK 6 DAY
3
DEXPAK PAK 10 DAY
3
DEXPAK PAK 13 DAY
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
76
Drug Name
hydrocortisone tab 5 mg
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
MEDROL TAB 2MG
methylprednisolone sodium succinate for
inj 40 mg
methylprednisolone sodium succinate for
inj 125 mg
methylprednisolone sodium succinate for
inj 500 mg
methylprednisolone sodium succinate for
inj 1000 mg
methylprednisolone tab 4 mg
methylprednisolone tab 4 mg dose pack
methylprednisolone tab 8 mg
methylprednisolone tab 16 mg
methylprednisolone tab 32 mg
MILLIPRED DP PAK 5MG
MILLIPRED SOL 10MG/5ML
MILLIPRED TAB 5MG
ORAPRED ODT TAB 10MG
ORAPRED ODT TAB 15MG
ORAPRED ODT TAB 30MG
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq)
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
PREDNISONE CON 5MG/ML
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 5 mg dose pack
prednisone tab 10 mg
prednisone tab 10 mg dose pack
prednisone tab 20 mg
prednisone tab 50 mg
SOLU-CORTEF INJ 250MG
SOLU-CORTEF INJ 500MG
SOLU-CORTEF INJ 1000MG
SOLU-MEDROL INJ 2GM
VERIPRED 20 SOL 20MG/5ML
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
1
1
1
2
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
1
1
1
1
2
1
1
1
1
1
1
1
1
1
3
3
3
3
3
ST - Step Therapy
PA** - PA Applies if
77
Drug Name
Drug Tier Requirements/Limits
Mineralocorticoids
fludrocortisone acetate tab 0.1 mg
1
COUGH/COLD/ALLERGY
Antitussives
benzonatate cap 100 mg
1
benzonatate cap 200 mg
1
hydrocodone w/ homatropine syrup 5-1.5 1
mg/5ml
hydrocodone w/ homatropine tab 5-1.5 mg 1
hydromet syp 5-1.5/5
1
tussigon tab 5mg
1
Cough/Cold/Allergy Combinations
ALLFEN CDX LIQ
CODEINE/GUAI LIQ 10-300MG
guaifenesin-codeine liquid 200-10 mg/5ml
prometh vc syp 6.25-5/5
prometh vc/ syp codeine
promethazine w/ codeine syrup 6.25-10
mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml
sudatuss-2 sol
sudatuss-sf sol
tgq 50pse/3 syp brm/30dm
ZODRYL DAC SUS 50
ZODRYL DAC SUS 60
ZODRYL DAC SUS 80
2
1
1
1
1
1
1
1
1
1
3
3
3
Misc. Respiratory Inhalants
sodium
sodium
sodium
sodium
chloride
chloride
chloride
chloride
soln
soln
soln
soln
nebu
nebu
nebu
nebu
0.9%
3%
7%
10%
1
1
1
1
Mucolytics
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
1
1
DERMATOLOGICALS
Acne Products
ACANYA GEL 1.2-2.5%
adapalene cream 0.1%
3
1
adapalene gel 0.1%
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
ST
PA; PA applies for
members age 25 and
older
PA; PA applies for
members age 25 and
older
PA** - PA Applies if
78
Drug Name
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
ATRALIN GEL 0.05%
AVAR GEL 10-5%
avar-e green cre 10-5%
avita cre 0.025%
avita gel 0.025%
AZELEX CRE 20%
BENZAMYCIN GEL PAK
BENZASHAVE 5 CRE 5%
benzashave cre 10%
benzepro aer 5.3%
benzepro sc aer 9.8%
BENZIQ GEL 5.25%
BENZIQ LS GEL 2.75%
benziq wash liq 5.25%
benzoyl per kit 4% wash
benzoyl per kit 8% wash
benzoyl per liq 2.5%wash
benzoyl per liq 4% crem
benzoyl per liq 8% crem
benzoyl per lot 3%
benzoyl per lot 4%
benzoyl per lot 6%
benzoyl per lot 8%
benzoyl per lot 9%
benzoyl pero kit acne pck
benzoyl peroxide cleanser 4.25%
benzoyl peroxide cream 3.5%
benzoyl peroxide cream 5.5%
benzoyl peroxide cream 8.5%
benzoyl peroxide foam 5.3%
benzoyl peroxide foam 9.8%
benzoyl peroxide pad 3%
benzoyl peroxide pad 6%
benzoyl peroxide pad 9%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
1
PA
1
PA
1
PA
3
PA; PA applies for
members age 35 and
older
2
1
1
PA; PA applies for
members age 35 and
older
1
PA; PA applies for
members age 35 and
older
3
ST
2
2
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
79
Drug Name
benzoyl peroxide-erythromycin gel 5-3%
bp 7% wash kit
bp gel gel 5%
bp wash liq 2.5%
bp wash liq 7%
BPO CLOTHS MIS 3%
BPO CLOTHS MIS 6%
BPO CLOTHS MIS 9%
BPO GEL 4%
BPO GEL 8%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clearplex x gel 10%
clenia cre 10-5%
CLINAC BPO GEL 7%
clindamax gel 1%
clindamax lot 10mg/ml
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
clindamycin phosphate-benzoyl peroxide
gel 1-5%
DELOS LIQ 3.5%
DELOS LOT 3.5%
DIFFERIN GEL 0.3%
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
2
2
1
PA
1
PA
1
PA
1
PA
1
1
2
1
1
1
1
1
1
1
1
1
1
2
3
DIFFERIN LOT 0.1%
3
EPIDUO GEL 0.1-2.5%
ery pad 2%
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
lavoclen-4 kit acne wsh
lavoclen-4 liq crem wsh
lavoclen-8 kit acne wsh
3
1
1
1
1
1
1
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; PA applies for
members age 25 and
older
PA; PA applies for
members age 25 and
older
PA** - PA Applies if
80
Drug Name
lavoclen-8 liq crem wsh
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 40mg
oscion clnsr lot 6%
oscion clnsr lot 9%
PACNEX HP PAD 7%
PACNEX LP PAD 4.25%
pacnex wash liq 7%
pr benzoyl liq 7% wash
se bpo cloth mis 3%
se bpo cloth mis 6%
se bpo cloth mis 9%
se bpo wash liq 7%
sotret cap 10mg
sotret cap 20mg
sotret cap 30mg
sulfacetamide sodium lotion 10% (acne)
sulfacetamide sodium w/ sulfur cleansing
cloth 10-5%
sulfacetamide sodium w/ sulfur cleansing
pad 10-4%
sulfacetamide sodium w/ sulfur cream 105%
sulfacetamide sodium w/ sulfur lotion 105%
suphera cre 10-5%
topisulf cre 10-5%
TRETIN-X CRE 0.075%
Drug Tier Requirements/Limits
1
1
PA
1
PA
1
PA
1
1
2
2
1
1
1
1
1
1
1
PA
1
PA
1
PA
1
1
1
1
1
1
1
3
TRETIN-X CRE 0.0375%
3
tretinoin cream 0.1%
1
tretinoin cream 0.05%
1
tretinoin cream 0.025%
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA** - PA Applies if
81
Drug Name
tretinoin gel 0.01%
Drug Tier Requirements/Limits
1
PA; PA applies for
members age 35 and
older
1
PA; PA applies for
members age 35 and
older
1
PA; PA applies for
members age 35 and
older
1
PA; PA applies for
members age 35 and
older
3
PA; PA applies for
members age 35 and
older
3
PA; PA applies for
members age 35 and
older
tretinoin gel 0.025%
tretinoin microsphere gel 0.1%
tretinoin microsphere gel 0.04%
VELTIN GEL
ZIANA GEL
Agents for External Genital and Perianal Warts
VEREGEN OIN 15%
3
Anti-inflammatory Agents - Topical
VOLTAREN GEL 1%
3
ST
Antibiotics - Topical
ALTABAX OIN 1%
CORTISPORIN CRE 0.5%
CORTISPORIN OIN 1%
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
mupirocin oint 2%
3
3
3
1
1
1
Antifungals - Topical
ciclopirox gel 0.77%
ciclopirox olamine cream 0.77% (base
equiv)
ciclopirox olamine susp 0.77% (base
equiv)
ciclopirox shampoo 1%
clotrimazole cream 1%
CLOTRIMAZOLE CRY
clotrimazole soln 1%
clotrimazole w/ betamethasone cream 10.05%
clotrimazole w/ betamethasone lotion 10.05%
econazole nitrate cream 1%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
3
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
82
Drug Name
ERTACZO CRE 2%
EXELDERM CRE 1%
EXELDERM SOL 1%
ketoconazole cream 2%
ketoconazole foam 2%
ketoconazole shampoo 2%
MENTAX CRE 1%
NAFTIN CRE 1%
NAFTIN CRE 2%
NAFTIN GEL 1%
NAFTIN GEL 2%
nyamyc pow 100000
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
nystop pow 100000
OXISTAT CRE 1%
OXISTAT LOT 1%
pedi-dri pow 100000
XOLEGEL GEL 2%
Drug Tier Requirements/Limits
3
3
3
1
1
1
3
3
3
3
3
1
1
1
1
1
1
1
3
3
1
3
Antineoplastic or Premalignant Lesion Agents - Topical
CARAC CRE 0.5%
FLUOROPLEX CRE 1%
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
PANRETIN GEL 0.1%
PICATO GEL 0.05%
PICATO GEL 0.015%
TARGRETIN GEL 1%
3
3
1
1
1
3
3
3
4
PA
Antipruritics - Topical
prudoxin cre 5%
1
Antipsoriatics
acitretin cap 10 mg
acitretin cap 17.5 mg
acitretin cap 25 mg
AMEVIVE INJ 15MG
calcipotriene cream 0.005%
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/ml)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
4
1
1
1
ST - Step Therapy
PA** - PA Applies if
83
Drug Name
calcitrene oin 0.005%
calcitriol oint 3 mcg/gm
8-MOP CAP 10MG
OXSORALEN-UL CAP 10MG
STELARA INJ 45MG/0.5
STELARA INJ 90MG/ML
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
TAZORAC GEL 0.1%
TAZORAC GEL 0.05%
Drug Tier Requirements/Limits
1
1
3
3
4
PA, ST
4
PA, ST
2
PA
2
PA
2
PA
2
PA
Antiseborrheic Products
selenium sulfide lotion 2.5%
1
Antivirals - Topical
acyclovir oint 5%
DENAVIR CRE 1%
1
3
Burn Products
mafenide acetate packet for topical soln
5% (50 gm)
silver sulfadiazine cream 1%
ssd cre 1%
SULFAMYLON CRE 85MG/GM
thermazene cre 1%
1
1
1
3
1
Corticosteroids - Topical
ala cort cre 1%
alclometasone dipropionate cream 0.05%
alclometasone dipropionate oint 0.05%
alphatrex gel 0.05%
amcinonide cream 0.1%
amcinonide lotion 0.1%
AMCINONIDE OIN 0.1%
apexicon oin 0.05%
betamethasone dipropionate augmented
cream 0.05%
betamethasone dipropionate augmented
lotion 0.05%
betamethasone dipropionate augmented
oint 0.05%
betamethasone dipropionate cream 0.05%
betamethasone dipropionate lotion 0.05%
betamethasone dipropionate oint 0.05%
betamethasone valerate aerosol foam
0.12%
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
betamethasone valerate oint 0.1%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
84
Drug Name
CAPEX SHA 0.01%
clobetasol propionate cream 0.05%
clobetasol propionate foam 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate lotion 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate shampoo 0.05%
clobetasol propionate soln 0.05%
CLOBEX SPR 0.05%
clocortolone pivalate cream 0.1%
CORDRAN 24X3 TAP 4MCG/CM
CORDRAN LOT 0.05%
CORDRAN SP CRE 0.05%
cormax oin 0.05%
DESONATE GEL 0.05%
desonide cream 0.05%
desonide lotion 0.05%
desonide oint 0.05%
DESOWEN OINT KIT 0.05%
desoximetasone cream 0.05%
desoximetasone cream 0.25%
desoximetasone gel 0.05%
desoximetasone oint 0.05%
desoximetasone oint 0.25%
diflorasone diacetate cream 0.05%
diflorasone diacetate oint 0.05%
fluocin acet oil body
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide cream 0.1%
fluocinonide cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate cream 0.05%
fluticasone propionate lotion 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate cream 0.05%
halobetasol propionate oint 0.05%
HALOG CRE 0.1%
HALOG OIN 0.1%
hydrocortisone butyrate cream 0.1%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
3
1
1
1
1
1
1
1
3
1
3
3
3
1
3
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
ST - Step Therapy
PA** - PA Applies if
85
Drug Name
Drug Tier Requirements/Limits
hydrocortisone butyrate hydrophilic lipo
1
base cream 0.1%
hydrocortisone butyrate oint 0.1%
1
hydrocortisone butyrate soln 0.1%
1
hydrocortisone cream 1%
1
hydrocortisone cream 2.5%
1
hydrocortisone lotion 2.5%
1
hydrocortisone oint 1%
1
hydrocortisone oint 2.5%
1
hydrocortisone valerate cream 0.2%
1
hydrocortisone valerate oint 0.2%
1
KENALOG AER SPRAY
3
lokara lot 0.05%
1
mometasone furoate cream 0.1%
1
mometasone furoate oint 0.1%
1
mometasone furoate solution 0.1% (lotion) 1
PEDIADERM HC KIT
3
PEDIADERM TA KIT
3
prednicarbate cream 0.1%
1
prednicarbate oint 0.1%
1
scalacort lot 2%
1
TACLONEX OIN
3
TACLONEX SUS
3
TEXACORT SOL 2.5%
3
triamcinolone acetonide cream 0.1%
1
triamcinolone acetonide cream 0.5%
1
triamcinolone acetonide cream 0.025%
1
triamcinolone acetonide lotion 0.1%
1
triamcinolone acetonide lotion 0.025%
1
triamcinolone acetonide oint 0.1%
1
triamcinolone acetonide oint 0.5%
1
triamcinolone acetonide oint 0.025%
1
TRIANEX OIN 0.05%
3
triderm cre 0.1%
1
VERDESO AER 0.05%
3
Emollients
laclotion lot 12%
1
lactic acid (ammonium lactate) cream 12% 1
lactic acid (ammonium lactate) lotion 10% 1
lactic acid (ammonium lactate) lotion 12% 1
Enzymes - Topical
SANTYL OIN 250/GM
3
Immunomodulating Agents - Topical
imiquimod cream 5%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
86
Drug Name
ZYCLARA CRE 3.75%
ZYCLARA PUMP CRE 2.5%
Drug Tier Requirements/Limits
3
3
Immunosuppressive Agents - Topical
ELIDEL CRE 1%
PROTOPIC OIN 0.1%
PROTOPIC OIN 0.03%
2
2
2
ST; PA**
ST; PA**
ST; PA**
Keratolytic/Antimitotic Agents
CONDYLOX GEL 0.5%
podofilox soln 0.5%
3
1
Local Anesthetics - Topical
lidocaine hcl cream 3%
lidocaine hcl gel 2%
lidocaine hcl lotion 3%
lidocaine hcl soln 4%
lidocaine oint 5%
lidocaine patch 5%
lidocaine-prilocaine cream 2.5-2.5%
lidocaine-prilocaine kit 2.5-2.5%
pramox gel 1%
SYNERA DIS 70-70MG
1
1
1
1
1
1
1
1
1
3
Rosacea Agents
FINACEA GEL 15%
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotion 0.75%
rosadan cre 0.75%
vitazol cre 0.75%
3
1
1
1
1
1
1
Scabicides Pediculicides
acticin cre 5%
EURAX CRE 10%
EURAX LOT 10%
lindane lotion 1%
lindane shampoo 1%
malathion lotion 0.5%
permethrin cream 5%
SKLICE LOT 0.5%
spinosad susp 0.9%
ULESFIA LOT 5%
1
3
3
1
1
1
1
3
1
3
Wound Care Products
REGRANEX GEL 0.01%
3
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
Dietary Management Products
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
87
Drug Name
folic acid-pyridoxine-cyanocobalamin tab
2.5-25-2 mg
Drug Tier Requirements/Limits
1
DIGESTIVE AIDS
Digestive Enzymes
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit
SUCRAID SOL 8500/ML
ULTRESA CAP 13800UNT
ULTRESA CAP 20700UNT
ULTRESA CAP 23000UNT
VIOKACE TAB
ZENPEP CAP 3000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
2
2
2
2
2
1
3
2
2
2
2
2
2
2
2
2
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide cap sr 12hr 500 mg
acetazolamide sodium for inj 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
1
1
1
1
1
1
Diuretic Combinations
ALDACTAZIDE TAB 50/50
amiloride & hydrochlorothiazide tab 5-50
mg
spironolactone & hydrochlorothiazide tab
25-25 mg
triamterene & hydrochlorothiazide cap
37.5-25 mg
triamterene & hydrochlorothiazide cap 5025 mg
triamterene & hydrochlorothiazide tab
37.5-25 mg
triamterene & hydrochlorothiazide tab 7550 mg
2
1
1
1
1
1
1
Loop Diuretics
bumetanide inj 0.25 mg/ml
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
88
Drug Name
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
EDECRIN TAB 25MG
furosemide inj 10 mg/ml
furosemide oral soln 10 mg/ml
FUROSEMIDE SOL 8MG/ML
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
SOD EDECRIN INJ 50MG
TORSEMIDE INJ 20MG/2ML
TORSEMIDE INJ 50MG/5ML
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
Drug Tier Requirements/Limits
1
1
1
3
1
1
2
1
1
1
3
3
3
1
1
1
1
Potassium Sparing Diuretics
amiloride hcl tab 5 mg
DYRENIUM CAP 50MG
DYRENIUM CAP 100MG
spironolactone tab 25 mg
spironolactone tab 50 mg
spironolactone tab 100 mg
1
3
3
1
1
1
Thiazides and Thiazide-Like Diuretics
chlorothiazide sodium for inj 500 mg
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
chlorthalidone tab 100 mg
DIURIL SUS 250/5ML
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methyclothiazide tab 5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
THALITONE TAB 15MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
2
ST - Step Therapy
PA** - PA Applies if
89
Drug Name
Drug Tier Requirements/Limits
ENDOCRINE AND METABOLIC AGENTS - MISC.
Bone Density Regulators
ACTONEL TAB 5MG
ACTONEL TAB 30MG
ACTONEL TAB 35MG
ACTONEL TAB 150MG
alendronate sodium tab 5 mg
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
alendronate sodium tab 40 mg
alendronate sodium tab 70 mg
ATELVIA TAB
calcitonin (salmon) nasal soln 200 unit/act
etidronate disodium tab 200 mg
etidronate disodium tab 400 mg
FORTEO SOL 600/2.4
FOSAMAX + D TAB 70-2800
FOSAMAX + D TAB 70-5600
FOSAMAX SOL
ibandronate sodium iv soln 3 mg/3ml
(base equivalent)
ibandronate sodium tab 150 mg (base
equivalent)
MIACALCIN INJ 200/ML
pamidronate disodium for inj 30 mg
pamidronate disodium for inj 90 mg
pamidronate disodium iv soln 3 mg/ml
pamidronate disodium iv soln 9 mg/ml
PAMIDRONATE INJ 6MG/ML
PROLIA SOL 60MG/ML
SKELID TAB 200MG
XGEVA INJ
zoledronic acid inj conc for iv infusion 4
mg/5ml
zoledronic acid iv soln 5 mg/100ml
ZOMETA INJ 4MG/100
3
3
3
3
1
1
1
1
1
3
1
1
1
4
3
3
3
1
ST
ST
ST
ST
ST
PA
ST
ST
1
3
1
1
1
1
3
4
3
4
4
PA
PA
PA
4
4
PA
PA
4
4
4
PA
PA
PA
Fertility Regulators
chorionic gonadotropin for inj 10000 unit
novarel inj 10000unt
pregnyl inj 10000unt
Growth Hormone Receptor Antagonists
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
ST - Step Therapy
PA
PA
PA
PA** - PA Applies if
90
Drug Name
Drug Tier Requirements/Limits
Growth Hormones
GENOTROPIN INJ 0.2MG
GENOTROPIN INJ 0.4MG
GENOTROPIN INJ 0.6MG
GENOTROPIN INJ 0.8MG
GENOTROPIN INJ 1.2MG
GENOTROPIN INJ 1.4MG
GENOTROPIN INJ 1.6MG
GENOTROPIN INJ 1.8MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
GENOTROPIN INJ 12MG
HUMATROPE INJ 5MG
HUMATROPE INJ 6MG
HUMATROPE INJ 12MG
HUMATROPE INJ 24MG
NORDITROPIN INJ 5/1.5ML
NORDITROPIN INJ 10/1.5ML
NORDITROPIN INJ 15/1.5ML
NORDITROPIN INJ 30/3ML
NUTROPIN AQ INJ 10MG/2ML
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ INJ NUSPIN 5
NUTROPIN INJ 10MG
OMNITROPE INJ 5.8MG
OMNITROPE INJ 5/1.5ML
OMNITROPE INJ 10/1.5ML
SAIZEN INJ 5MG
SAIZEN INJ 8.8MG
SEROSTIM INJ 4MG
SEROSTIM INJ 5MG
SEROSTIM INJ 6MG
TEV-TROPIN INJ 5MG
ZORBTIVE INJ 8.8MG
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA
PA
PA
PA
PA
PA
PA
PA
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA,
PA
PA
PA
PA,
PA
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Hormone Receptor Modulators
EVISTA TAB 60MG
2
Insulin-Like Growth Factors (Somatomedins)
INCRELEX INJ 40MG/4ML
4
PA
LHRH/GnRH Agonist Analog Pituitary Suppressants
LUPR
LUPR
LUPR
LUPR
DEP-PED
DEP-PED
DEP-PED
DEP-PED
INJ
INJ
INJ
INJ
7.5MG
11.25MG
15MG
30MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA
PA** - PA Applies if
91
Drug Name
SYNAREL SOL 2MG/ML
Drug Tier Requirements/Limits
2
Metabolic Modifiers
ALDURAZYME INJ 2.9MG/5M
BUPHENYL TAB 500MG
calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
CARBAGLU TAB 200MG
CYSTADANE POW
doxercalciferol cap 0.5 mcg
doxercalciferol cap 1 mcg
doxercalciferol cap 2.5 mcg
doxercalciferol inj 4 mcg/2ml (2 mcg/ml)
ELAPRASE INJ 6MG/3ML
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
KUVAN TAB 100MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
paricalcitol cap 1 mcg
paricalcitol cap 2 mcg
paricalcitol cap 4 mcg
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
sodium phenylbutyrate oral powder 3
gm/teaspoonful
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
4
4
1
1
1
1
4
4
1
1
1
1
4
4
4
4
4
4
4
4
4
1
1
1
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
3
3
Posterior Pituitary Hormones
desmopressin acetate
desmopressin acetate
(refrigerated)
desmopressin acetate
0.01%
desmopressin acetate
0.01% (refrigerated)
desmopressin acetate
desmopressin acetate
minirin spr nasal
inj 4 mcg/ml
nasal soln 0.01%
1
1
nasal spray soln
1
nasal spray soln
1
tab 0.1 mg
tab 0.2 mg
1
1
1
Prolactin Inhibitors
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
92
Drug Name
cabergoline tab 0.5 mg
Drug Tier Requirements/Limits
1
Somatostatic Agents
octreotide acetate inj 50 mcg/ml (0.05
mg/ml)
octreotide acetate inj 100 mcg/ml (0.1
mg/ml)
octreotide acetate inj 200 mcg/ml (0.2
mg/ml)
octreotide acetate inj 500 mcg/ml (0.5
mg/ml)
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMATULINE INJ 120/.5ML
4
PA
4
PA
4
PA
4
PA
4
PA
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
4
4
PA
PA
Vasopressin Receptor Antagonists
SAMSCA TAB 15MG
SAMSCA TAB 30MG
ESTROGENS
Estrogen Combinations
CLIMARA PRO DIS WEEKLY
2
estradiol & norethindrone acetate tab 0.5- 1
0.1 mg
estradiol & norethindrone acetate tab 1-0.5 1
mg
FEMHRT TAB 0.5-2.5
2
jevantique tab 1mg-5mcg
1
jinteli tab 1mg-5mcg
1
mimvey tab 1-0.5mg
1
Estrogens
ALORA DIS 0.1MG
3
ALORA DIS 0.05MG
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
93
Drug Name
ALORA DIS 0.025MG
ALORA DIS 0.075MG
CENESTIN TAB 0.3MG
CENESTIN TAB 0.9MG
CENESTIN TAB 0.45MG
CENESTIN TAB 0.625MG
CENESTIN TAB 1.25MG
DEPO-ESTRADI INJ 5MG/ML
DIVIGEL GEL 0.5MG
DIVIGEL GEL 0.25MG
DIVIGEL GEL 1MG/GM
ELESTRIN GEL 0.06%
ENJUVIA TAB 0.3MG
ENJUVIA TAB 0.9MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
3
3
3
3
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
ST - Step Therapy
PA** - PA Applies if
94
Drug Name
ENJUVIA TAB 0.45MG
ENJUVIA TAB 0.625MG
ENJUVIA TAB 1.25MG
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.1 mg/24hr
estradiol td patch weekly 0.05 mg/24hr
estradiol td patch weekly 0.06 mg/24hr
estradiol td patch weekly 0.025 mg/24hr
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
ST - Step Therapy
PA** - PA Applies if
95
Drug Name
estradiol td patch weekly 0.075 mg/24hr
Drug Tier Requirements/Limits
1
PA; High Risk
Medications require PA
for members age 65 and
older
estradiol td patch weekly 0.0375 mg/24hr 1
PA; High Risk
(37.5 mcg/24hr)
Medications require PA
for members age 65 and
older
estradiol valerate im in oil 10 mg/ml
1
estradiol valerate im in oil 20 mg/ml
1
estradiol valerate im in oil 40 mg/ml
1
ESTROGEL GEL
3
estropipate tab 0.75 mg
1
PA; High Risk
Medications require PA
estropipate tab 1.5 mg
1
estropipate tab 3 mg
1
EVAMIST SPR 1.53MG
MENEST TAB 0.3MG
3
3
MENEST TAB 0.625MG
3
MENEST TAB 1.25MG
3
MENEST TAB 2.5MG
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
96
Drug Name
MENOSTAR DIS 14MCG
ortho-est tab 0.625
ortho-est tab 1.25
PREMARIN INJ 25MG
PREMARIN TAB 0.3MG
PREMARIN TAB 0.9MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 1.25MG
VIVELLE-DOT DIS 0.1MG
VIVELLE-DOT DIS 0.05MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
3
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
3
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
ST - Step Therapy
PA** - PA Applies if
97
Drug Name
VIVELLE-DOT DIS 0.025MG
Drug Tier Requirements/Limits
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
3
PA; High Risk
Medications require PA
for members age 65 and
older
VIVELLE-DOT DIS 0.075MG
VIVELLE-DOT DIS 0.0375MG
FLUOROQUINOLONES
Fluoroquinolones
AVELOX INJ
CIPRO (5%) SUS 250MG/5
CIPRO (10%) SUS 500MG/5
ciprofloxacin 200 mg/100ml in d5w
ciprofloxacin 400 mg/200ml in d5w
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin hcl tab 250 mg (base equiv)
ciprofloxacin hcl tab 500 mg (base equiv)
ciprofloxacin hcl tab 750 mg (base equiv)
ciprofloxacin iv soln 200 mg/20ml (1%)
ciprofloxacin iv soln 400 mg/40ml (1%)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)
FACTIVE TAB 320MG
levofloxacin in d5w iv soln 250 mg/50ml
levofloxacin in d5w iv soln 500 mg/100ml
levofloxacin in d5w iv soln 750 mg/150ml
levofloxacin iv soln 25 mg/ml
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
moxifloxacin hcl tab 400 mg (base equiv)
NOROXIN TAB 400MG
ofloxacin tab 200 mg
ofloxacin tab 300 mg
ofloxacin tab 400 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
2
2
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
3
1
1
1
ST - Step Therapy
PA** - PA Applies if
98
Drug Name
Drug Tier Requirements/Limits
GASTROINTESTINAL AGENTS - MISC.
Gallstone Solubilizing Agents
ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
1
1
1
Gastrointestinal Antiallergy Agents
cromolyn sodium oral conc 100 mg/5ml
1
Gastrointestinal Chloride Channel Activators
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
2
2
PA
PA
Gastrointestinal Stimulants
metoclopramide
metoclopramide
mg/10ml)
metoclopramide
metoclopramide
METOZOLV ODT
METOZOLV ODT
hcl inj 5 mg/ml
hcl soln 5 mg/5ml (10
1
1
hcl tab 5 mg
hcl tab 10 mg
TAB 5MG
TAB 10MG
1
1
3
3
Inflammatory Bowel Agents
APRISO CAP 0.375GM
balsalazide disodium cap 750 mg
CANASA SUP 1000MG
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
DIPENTUM CAP 250MG
mesalamine enema 4 gm
mesalamine rectal enema 4 gm & cleanser
wipe kit
REMICADE INJ 100MG
sulfasalazine tab 500 mg
sulfasalazine tab delayed release 500 mg
sulfazine tab 500mg
2
1
2
4
4
4
3
1
1
4
1
1
1
PA, ST
PA, ST
PA, ST
PA, ST
Intestinal Acidifiers
enulose sol 10gm/15
generlac sol 10gm/15
1
1
Irritable Bowel Syndrome (IBS) Agents
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
3
3
PA
PA
Peripheral Opioid Receptor Antagonists
RELISTOR INJ 8/0.4ML
RELISTOR INJ 12/0.6ML
3
3
PA
PA
Phosphate Binder Agents
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
99
Drug Name
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)
calcium acetate (phosphate binder) tab
667 mg
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
FOSRENOL CHW 1000MG
PHOSLYRA SOL
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
Drug Tier Requirements/Limits
1
1
3
3
3
3
2
2
2
GENITOURINARY AGENTS - MISCELLANEOUS
Alkalinizers
potassium citrate tab cr 5 meq (540 mg) 1
potassium citrate tab cr 10 meq (1080 mg) 1
potassium citrate tab cr 15 meq (1620 mg) 1
Cystinosis Agents
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
4
4
PA
PA
Genitourinary Irrigants
sodium chloride irrigation soln 0.9%
1
Interstitial Cystitis Agents
ELMIRON CAP 100MG
3
Prostatic Hypertrophy Agents
alfuzosin hcl tab sr 24hr 10 mg
AVODART CAP 0.5MG
CARDURA XL TAB 4MG
CARDURA XL TAB 8MG
finasteride tab 5 mg
JALYN CAP
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
tamsulosin hcl cap 0.4 mg
1
3
3
3
1
3
3
3
1
ST
ST
ST
ST
ST
ST
Urinary Analgesics
phenazopyridine hcl tab 100 mg
phenazopyridine hcl tab 200 mg
1
1
GOUT AGENTS
Gout Agent Combinations
colchicine w/ probenecid tab 0.5-500 mg
1
Gout Agents
allopurinol sodium for inj 500 mg
allopurinol tab 100 mg
allopurinol tab 300 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
ST - Step Therapy
PA** - PA Applies if
100
Drug Name
COLCRYS TAB 0.6MG
ULORIC TAB 40MG
ULORIC TAB 80MG
Drug Tier Requirements/Limits
2
3
ST; PA**
3
ST; PA**
Uricosurics
probenecid tab 500 mg
1
HEMATOLOGICAL AGENTS - MISC.
Bradykinin B2 Receptor Antagonists
FIRAZYR INJ 30MG/3ML
4
PA
Hematorheologic Agents
pentopak tab 400mg cr
pentoxifylline tab cr 400 mg
1
1
Platelet Aggregation Inhibitors
AGGRENOX CAP 25-200MG
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
BRILINTA TAB 90MG
cilostazol tab 50 mg
cilostazol tab 100 mg
clopidogrel bisulfate tab 75 mg (base
equiv)
clopidogrel bisulfate tab 300 mg (base
equiv)
dipyridamole tab 25 mg
2
1
1
2
1
1
1
dipyridamole tab 50 mg
1
dipyridamole tab 75 mg
1
EFFIENT TAB 5MG
EFFIENT TAB 10MG
ticlopidine hcl tab 250 mg
2
2
1
1
1
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
HEMATOPOIETIC AGENTS
Agents for Gaucher Disease
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
ELELYSO INJ 200UNIT
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
ST - Step Therapy
PA
PA
PA
PA** - PA Applies if
101
Drug Name
VPRIV INJ 400UNIT
ZAVESCA CAP 100MG
Drug Tier Requirements/Limits
4
PA
4
PA
Agents for Sickle Cell Anemia
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
2
2
2
Cobalamins
cobal-1000 inj 1000mcg
cyanocobalamin inj 1000 mcg/ml
1
1
Folic Acid/Folates
folic acid tab 1 mg
folic acid tab 400 mcg
1
0
folic acid tab 800 mcg
0
QL (100 tabs / 30 days);
OTC; $0 applies for ages
55 and under
QL (100 tabs / 30 days);
OTC; $0 applies for ages
55 and under
Hematopoietic Growth Factors
ARANESP INJ 25MCG
ARANESP INJ 40MCG
ARANESP INJ 60MCG
ARANESP INJ 100MCG
ARANESP INJ 150MCG
ARANESP INJ 200MCG
ARANESP INJ 300MCG
ARANESP INJ 500MCG
LEUKINE INJ 250MCG
LEUKINE INJ 500 MCG
NEULASTA INJ 6MG/0.6M
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
OMONTYS INJ 10MG/ML
OMONTYS INJ 20MG/2ML
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 40000/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
102
Drug Name
PROMACTA TAB 50MG
PROMACTA TAB 75MG
Drug Tier Requirements/Limits
4
PA
4
PA
Iron
FER-IN-SOL DRO 15MG/ML
0
FERROUS SUL LIQ 220/5ML
0
FERROUS SULF DRO
0
FERROUS SULF SYP 300/5ML
0
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe)
0
ferrous sulfate soln 75 mg/0.6ml (15
mg/0.6ml elemental fe)
0
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
0
ICAR PEDS SUS GRAPE
0
MYKIDZ IRON SUS 15/1.5ML
0
wee care sus 15/1.25
0
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
Stem Cell Mobilizers
MOZOBIL INJ
4
PA
HEMOSTATICS
Hemostatics - Systemic
tranexamic acid inj 100 mg/ml
tranexamic acid tab 650 mg
1
1
HYPNOTICS
Barbiturate Hypnotics
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
elixir 20 mg/5ml
tab 15 mg
tab 16.2 mg
tab 30 mg
tab 32.4 mg
tab 60 mg
tab 64.8 mg
tab 97.2 mg
tab 100 mg
1
1
1
1
1
1
1
1
1
Non-Barbiturate Hypnotics
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
103
Drug Name
LUNESTA TAB 1MG
Drug Tier Requirements/Limits
3
QL (15 tabs / 25 days),
ST
3
QL (15 tabs / 25 days),
ST
3
QL (15 tabs / 25 days),
ST
1
QL (15 caps / 25 days)
1
QL (15 caps / 25 days)
1
QL (15 caps / 25 days)
1
QL (15 caps / 25 days)
1
QL (15 caps / 25 days)
1
QL (15 caps / 25 days)
1
QL (15 tabs / 25 days)
1
QL (15 tabs / 25 days)
1
QL (15 tabs / 25 days)
1
QL (15 tabs / 25 days)
LUNESTA TAB 2MG
LUNESTA TAB 3MG
temazepam cap 7.5 mg
temazepam cap 15 mg
temazepam cap 22.5 mg
temazepam cap 30 mg
zaleplon cap 5 mg
zaleplon cap 10 mg
zolpidem tartrate tab 5 mg
zolpidem tartrate tab 10 mg
zolpidem tartrate tab cr 6.25 mg
zolpidem tartrate tab cr 12.5 mg
Selective Melatonin Receptor Agonists
ROZEREM TAB 8MG
3
QL (15 tabs / 25 days),
ST
LAXATIVES
Laxative Combinations
COLYTE/FLAVR SOL PACKS
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
GOLYTELY SOL
MOVIPREP SOL
2
1
1
1
2
2
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 240 gm
peg 3350-kcl-sod bicarb-nacl for soln 420
gm
PREPOPIK PAK
1
SUPREP BOWEL SOL PREP
3
trilyte sol
1
$0 copay for members
age 50 through 74.
1
1
0
PA; $0 only for
members age 50
through 74.
$0 copay for members
age 50 through 74.
Laxatives - Miscellaneous
constulose sol 10gm/15
KRISTALOSE PAK 10GM
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
3
ST - Step Therapy
PA** - PA Applies if
104
Drug Name
KRISTALOSE PAK 20GM
lactulose solution 10 gm/15ml
polyethylene glycol 3350 oral packet
Drug Tier Requirements/Limits
3
1
1
Saline Laxatives
OSMOPREP TAB 1.5GM
VISICOL TAB 1.5GM
3
3
LOCAL ANESTHETICS-Parenteral
Local Anesthetics - Amides
LIDO/DEXTROS INJ 5-7.5%
lidocaine hcl local inj 0.5%
lidocaine hcl local inj 1%
lidocaine hcl local inj 1.5%
lidocaine hcl local inj 2%
lidocaine hcl local inj 4%
lidocaine hcl local preservative free (pf) inj
0.5%
lidocaine hcl local preservative free (pf) inj
1%
lidocaine hcl local preservative free (pf) inj
2%
3
1
1
1
1
1
1
1
1
MACROLIDES
Azithromycin
azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
azithromycin iv for soln 500 mg
azithromycin powd pack for susp 1 gm
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
ZMAX SUS 2GM
1
1
1
1
1
1
1
3
Clarithromycin
clarithromycin
clarithromycin
clarithromycin
clarithromycin
clarithromycin
for susp 125 mg/5ml
for susp 250 mg/5ml
tab 250 mg
tab 500 mg
tab sr 24hr 500 mg
1
1
1
1
1
Erythromycins
e.e.s. 400 tab 400mg
E.E.S. GRAN SUS 200/5ML
ERY-TAB TAB 250MG EC
ERY-TAB TAB 333MG EC
ERY-TAB TAB 500MG EC
ERYPED SUS 200/5ML
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
2
2
2
2
2
ST - Step Therapy
PA** - PA Applies if
105
Drug Name
ERYPED SUS 400/5ML
ERYTHROCIN INJ 500MG
ERYTHROCIN INJ 1000MG
erythrocin tab 250mg
erythromycin ethylsuccinate tab 400 mg
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin w/ delayed release particles
cap 250 mg
PCE TAB 333MG EC
PCE TAB 500MG EC
Drug Tier Requirements/Limits
2
3
3
1
1
1
1
1
3
3
Fidaxomicin
DIFICID TAB 200MG
2
PA
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
OTC
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
OTC
QL (1
MEDICAL DEVICES
Contraceptives
FC2 FEMALE MIS CONDOM
FEMCAP MIS 22MM
FEMCAP MIS 26MM
FEMCAP MIS 30MM
OMNIFLEX DPR
ORTHO COIL DPR KIT 50
ORTHO COIL DPR KIT 100
ORTHO COIL DPR KIT 105
ORTHO FLAT DPR KIT 55
ORTHO FLAT DPR KIT 60
ORTHO FLAT DPR KIT 65
ORTHO FLAT DPR KIT 70
ORTHO FLAT DPR KIT 75
ORTHO FLAT DPR KIT 80
ORTHO FLAT DPR KIT 85
ORTHO FLAT DPR KIT 90
ORTHO FLAT DPR KIT 95
ORTHO FLEX DPR 65MM
ORTHO FLEX DPR 70MM
ORTHO FLEX DPR 75MM
ORTHO FLEX DPR 80MM
PRENTIF MIS 22MM
PRENTIF MIS 25MM
PRENTIF MIS 28MM
PRENTIF MIS 31MM
PRENTIF MIS FITTING
TODAY SPONGE MIS
WIDE-SEAL DPR KIT 60
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
/ 300 days)
PA** - PA Applies if
106
Drug Name
WIDE-SEAL DPR
WIDE-SEAL DPR
WIDE-SEAL DPR
WIDE-SEAL DPR
WIDE-SEAL DPR
WIDE-SEAL DPR
WIDE-SEAL DPR
KIT
KIT
KIT
KIT
KIT
KIT
KIT
Drug Tier Requirements/Limits
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
65
70
75
80
85
90
95
Diabetic Supplies
ACCU-CHEK BLOOD GLUCOSE TEST KITS 2
ACCU-CHEK BLOOD GLUCOSE TEST
2
STRIPS
ALCOHOL PREP WIPES AND SWABS
2
BLOOD GLUCOSE CALIBRATION SOLUTION 2
INSULIN NEEDLES/SYRINGES
2
LANCETS
2
LANCING DEVICE
2
ONETOUCH BLOOD GLUCOSE TEST KITS 2
ONETOUCH BLOOD GLUCOSE TEST STRIPS 2
OTC
OTC
OTC
OTC
OTC
OTC
MIGRAINE PRODUCTS
Migraine Combinations
CAFERGOT TAB 1-100MG
ergotamine w/ caffeine tab 1-100 mg
2
1
Migraine Products
dihydroergotamine mesylate inj 1 mg/ml 1
dihydroergotamine mesylate nasal spray 4 1
mg/ml
ERGOMAR SUB 2MG
3
QL (8 kits / 25 days)
QL (8 kits / 25 days)
Serotonin Agonists
AXERT TAB 6.25MG
3
AXERT TAB 12.5MG
3
FROVA TAB 2.5MG
3
naratriptan hcl tab 1 mg (base equiv)
naratriptan hcl tab 2.5 mg (base equiv)
RELPAX TAB 20MG
1
1
3
RELPAX TAB 40MG
3
rizatriptan benzoate orally disintegrating
tab 5 mg
rizatriptan benzoate orally disintegrating
tab 10 mg
1
QL
ST
QL
ST
QL
ST
QL
QL
QL
ST
QL
ST
QL
1
QL (18 tabs / 25 days)
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
(12 tabs / 25 days),
(12 tabs / 25 days),
(18 tabs / 25 days),
(12 tabs / 25 days)
(12 tabs / 25 days)
(12 tabs / 25 days),
(12 tabs / 25 days),
(18 tabs / 25 days)
PA** - PA Applies if
107
Drug Name
rizatriptan benzoate tab 5 mg
rizatriptan benzoate tab 10 mg
sumatriptan nasal spray 5 mg/act
sumatriptan nasal spray 20 mg/act
sumatriptan succinate inj 6 mg/0.5ml
sumatriptan succinate solution autoinjector 4 mg/0.5ml
sumatriptan succinate solution autoinjector 6 mg/0.5ml
sumatriptan succinate tab 25 mg
sumatriptan succinate tab 50 mg
sumatriptan succinate tab 100 mg
zolmitriptan orally disintegrating tab 2.5
mg
zolmitriptan orally disintegrating tab 5 mg
zolmitriptan tab 2.5 mg
zolmitriptan tab 5 mg
ZOMIG SPR 2.5MG
ZOMIG SPR 5MG
Drug Tier Requirements/Limits
1
QL (18 tabs / 25 days)
1
QL (18 tabs / 25 days)
1
QL (24 sprays / 25
days)
1
QL (12 sprays / 25
days)
1
QL (6 kits / 25 days)
1
QL (6 kits / 25 days)
1
QL (6 kits / 25 days)
1
1
1
1
QL
QL
QL
QL
1
1
1
3
QL (12
QL (12
QL (12
QL (12
days)
QL (12
days)
3
(12
(12
(12
(12
tabs
tabs
tabs
tabs
/
/
/
/
25
25
25
25
days)
days)
days)
days)
tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
sprays / 25
sprays / 25
MINERALS ELECTROLYTES
Chloride
AMMONIUM CHL INJ 5MEQ/ML
3
Electrolyte Mixtures
ISOLYTE-S INJ
kcl 20 meq/l (0.15%) in nacl 0.9% inj
kcl 20 meq/l (0.15%) in nacl 0.45% inj
kcl 40 meq/l (0.3%) in nacl 0.9% inj
NORMOSOL -R INJ
PLASMA-LYTE INJ 56
PLASMA-LYTE INJ -148
PLASMA-LYTE INJ -A
3
1
1
1
3
3
3
3
Fluoride
epiflur chw 0.5mg f
0
epiflur chw 0.25mg f
0
epiflur chw 1mg f
fluor-a-day dro 0.125mg
1
0
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
$0 applies for ages 6
and under
$0 applies for ages 6
and under
$0 applies for ages 6
and under
PA** - PA Applies if
108
Drug Name
FLUORABON DRO
fluoritab chw 0.5mg f
fluoritab chw 2.2mg
fluoritab dro 0.125mg
flura-drops dro 0.25mg f
flura-drops dro 0.125mg
ludent chw 0.5mg f
ludent chw 0.25mg f
ludent chw 1mg f
LURIDE CHW 0.5MG F
LURIDE CHW 0.25MG F
LURIDE DRO 0.5MG/ML
nafrinse chw 1mg f
sodiphluor dro 1.1mg/ml
sodium fluoride chew tab
1.1 mg naf)
sodium fluoride chew tab
0.55 mg naf)
Drug Tier Requirements/Limits
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
1
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
1
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
0
$0 applies for ages 6
and under
1
0
$0 applies for ages 6
and under
0.5 mg f (from
0
$0 applies for ages 6
and under
0.25 mg f (from 0
$0 applies for ages 6
and under
1 mg f (from 2.2 1
sodium fluoride chew tab
mg naf)
sodium fluoride soln 0.5 mg/ml f (from 1.1 0
mg/ml naf)
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
0
sodium fluoride tab 0.5 mg f (from 1.1 mg 0
naf)
sodium fluoride tab 1 mg f (from 2.2 mg
naf)
$0 applies for ages 6
and under
$0 applies for ages 6
and under
$0 applies for ages 6
and under
1
Magnesium
MAGNESIUM SU INJ 40MG/ML
MAGNESIUM SU INJ 80MG/ML
magnesium sulfate inj 50%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
1
ST - Step Therapy
PA** - PA Applies if
109
Drug Name
MG SO4/D5W INJ 10MG/ML
MG SO4/D5W INJ 20MG/ML
Drug Tier Requirements/Limits
3
3
Potassium
klor-con 8 tab 8meq er
klor-con 10 tab 10meq er
KLOR-CON M15 TAB
klor-con m20 tab 20meq er
potassium chloride cap cr 8 meq
potassium chloride cap cr 10 meq
potassium chloride inj 2 meq/ml
potassium chloride inj 10 meq/50 ml
potassium chloride inj 10 meq/100 ml
potassium chloride inj 20 meq/50 ml
potassium chloride inj 20 meq/100 ml
potassium chloride inj 30 meq/100 ml
potassium chloride inj 40 meq/100 ml
potassium chloride microencapsulated crys
cr tab 10 meq
potassium chloride microencapsulated crys
cr tab 20 meq
potassium chloride oral liq 10% (20
meq/15ml)
potassium chloride oral liq 20% (40
meq/15ml)
potassium chloride tab cr 8 meq (600 mg)
potassium chloride tab cr 10 meq
POTASSIUM CHLORIDE TAB CR 20 MEQ
(1500 MG)
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
Sodium
sodium
sodium
sodium
sodium
sodium
sodium
sodium
chloride
chloride
chloride
chloride
chloride
chloride
chloride
inj 0.9%
inj 0.45%
inj 2.5 meq/ml (14.6%)
inj 3%
inj 4 meq/ml (23.4%)
inj 5%
iv soln 0.9%
1
1
1
1
1
1
1
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine hcl laryngotracheal soln 4%
lidocaine hcl viscous soln 2%
1
1
Anti-infectives - Throat
clotrimazole troche 10 mg
nystatin susp 100000 unit/ml
ORAVIG TAB 50MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
3
ST - Step Therapy
PA** - PA Applies if
110
Drug Name
Drug Tier Requirements/Limits
Antiallergy Agents - Mouth/Throat
APHTHASOL PST 5%
3
Antiseptics - Mouth/Throat
chlorhexidine gluconate soln 0.12%
periogard sol 0.12%
1
1
Steroids - Mouth/Throat
oralone pst 0.1%
1
triamcinolone acetonide dental paste 0.1% 1
Throat Products - Misc.
cevimeline hcl cap 30 mg
pilocarpine hcl tab 5 mg
pilocarpine hcl tab 7.5 mg
1
1
1
MULTIVITAMINS
Ped MV w/ Fluoride
acd/fluoride dro 0.25mg
multi-vit/fl chw 0.5mg
multi-vit/fl chw 0.25mg
multi-vit/fl chw 1mg
multi-vit/fl dro 0.5mg/ml
multi-vit/fl dro 0.25mg
multivit/fl chw 0.5mg
multivit/fl chw 0.25mg
multivit/fl chw 1mg
phluorivit dro
POLY-VI-FLOR CHW 0.5MG
POLY-VI-FLOR CHW 0.25MG
POLY-VI-FLOR CHW 1MG
poly-vit/fl dro 0.25mg
polyvit/fl dro 0.5mg/ml
tri-vit/fl dro 0.5mg
tri-vit/fl dro 0.25mg
tri-vit/fluo dro 0.5mg
tri-vit/fluo dro 0.25mg
tri-vita/fl dro 0.25mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Ped Multi Vitamins w/Fl FE
MULTI-VIT/FE DRO /FL 0.25
MULTI-VIT/FL DRO /FE 0.25
PHLUORIVIT + DRO FE
poly-vit/fe dro /fl 0.5
POLY-VIT/FE DRO /FL 0.25
tri-vit/fe dro /fl 0.25
1
1
1
1
1
1
Prenatal Vitamins
CITRANATAL CAP HARMONY
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
2
ST - Step Therapy
PA** - PA Applies if
111
Drug Name
CITRANATAL
CITRANATAL
CITRANATAL
CITRANATAL
CITRANATAL
MIS
MIS
PAK
PAK
TAB
Drug Tier Requirements/Limits
2
2
2
2
2
90 DHA
B-CALM
ASSURE
DHA
RX
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 250 mg
1
1
1
carisoprodol tab 350 mg
1
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
chlorzoxazone tab 500 mg
cyclobenzaprine hcl tab 5 mg
1
1
cyclobenzaprine hcl tab 7.5 mg
1
cyclobenzaprine hcl tab 10 mg
1
metaxalone tab 800 mg
1
methocarbamol tab 500 mg
1
methocarbamol tab 750 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
112
Drug Name
orphenadrine citrate inj 30 mg/ml
orphenadrine citrate tab sr 12hr 100 mg
tizanidine
tizanidine
tizanidine
tizanidine
tizanidine
hcl
hcl
hcl
hcl
hcl
cap 2 mg
cap 4 mg
cap 6 mg
tab 2 mg
tab 4 mg
Drug Tier Requirements/Limits
1
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
1
1
1
1
Direct Muscle Relaxants
dantrolene sodium cap 25 mg
dantrolene sodium cap 50 mg
dantrolene sodium cap 100 mg
1
1
1
Muscle Relaxant Combinations
orphen cpd tab ds
1
orphenadrine w/ aspirin & caffeine tab 25- 1
385-30 mg
PA; High Risk
Medications require PA
for members age 65 and
older
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Anti-infectives
BACTROBAN OIN NASAL 2%
3
Nasal Antiallergy
ASTEPRO SPR 0.15%
azelastine hcl nasal spray 137 mcg/spray
(1 mg/ml)
PATANASE SPR 0.6%
3
1
QL (2 bottles / 25 days)
QL (2 bottles / 25 days)
3
QL (1 container / 25
days)
Nasal Anticholinergics
ipratropium bromide nasal soln 0.03% (21 1
mcg/spray)
ipratropium bromide nasal soln 0.06% (42 1
mcg/spray)
Nasal Steroids
flunisolide nasal soln 25 mcg/act (0.025%) 1
flunisolide nasal soln 29 mcg/act (0.025%) 1
fluticasone propionate nasal susp 50
mcg/act
1
NASONEX SPR 50MCG/AC
3
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (2 containers / 25
days)
QL (2 containers / 25
days)
QL (1 container / 25
days)
QL (2 inhalers / 25
days), ST
PA** - PA Applies if
113
Drug Name
triamcinolone acetonide nasal inhal 55
mcg/act
Drug Tier Requirements/Limits
1
QL (1 container / 25
days)
Sympathomimetic Decongestants
TYZINE PED DRO 0.05%
TYZINE SOL 0.1%
3
3
NEUROMUSCULAR AGENTS
ALS Agents
riluzole tab 50 mg
1
Neuromuscular Blocking Agent - Neurotoxins
BOTOX INJ 100UNIT
BOTOX INJ 200UNIT
XEOMIN INJ 50 UNIT
XEOMIN INJ 100UNIT
4
4
4
4
PA
PA
PA
PA
OPHTHALMIC AGENTS
Artificial Tears and Lubricants
LACRISERT MIS 5MG OP
3
Beta-blockers - Ophthalmic
betaxolol hcl ophth soln 0.5%
1
BETIMOL SOL 0.5%
3
BETIMOL SOL 0.25%
3
BETOPTIC-S SUS 0.25% OP
2
carteolol hcl ophth soln 1%
1
COMBIGAN SOL 0.2/0.5%
2
dorzolamide hcl-timolol maleate ophth soln 1
22.3-6.8 mg/ml
ISTALOL SOL 0.5% OP
3
levobunolol hcl ophth soln 0.5%
1
levobunolol hcl ophth soln 0.25%
1
metipranolol ophth soln 0.3%
1
timolol maleate ophth gel forming soln
1
0.5%
timolol maleate ophth gel forming soln
1
0.25%
timolol maleate ophth soln 0.5%
1
timolol maleate ophth soln 0.25%
1
TIMOPTIC OCU SOL 0.5% OP
2
TIMOPTIC OCU SOL 0.25% OP
2
Cycloplegic Mydriatics
atropine sulfate ophth oint 1%
atropine sulfate ophth soln 1%
homatropaire sol 5% op
homatropine hbr ophth soln 5%
ISO HOMATROP SOL 2% OP
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
3
ST - Step Therapy
PA** - PA Applies if
114
Drug Name
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
Drug Tier Requirements/Limits
1
1
Miotics
PHOSPHOLINE SOL 0.125%OP
PILOPINE HS GEL 4% OP
3
3
Ophthalmic Adrenergic Agents
ALPHAGAN P SOL 0.1%
apraclonidine hcl ophth soln 0.5% (base
equivalent)
brimonidine tartrate ophth soln 0.2%
brimonidine tartrate ophth soln 0.15%
IOPIDINE SOL 1% OP
3
1
1
1
3
Ophthalmic Anti-infectives
AZASITE SOL 1%
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
BESIVANCE SUS 0.6%
CILOXAN OIN 0.3% OP
ciprofloxacin hcl ophth soln 0.3%
erythromycin ophth oint 5 mg/gm
garamycin oin 0.3% op
gatifloxacin ophth soln 0.5%
gentak oin 0.3% op
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
gentasol sol 0.3% op
ilotycin oin op
levofloxacin ophth soln 0.5%
MOXEZA SOL 0.5%
NATACYN SUS 5% OP
neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
polycin oin op
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1%
romycin oin op
sulfacetamide sodium ophth soln 10%
tobramycin ophth soln 0.3%
TOBREX OIN 0.3% OP
trifluridine ophth soln 1%
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
ZYMAR DRO 0.3%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
1
1
3
2
1
1
1
1
1
1
1
1
1
1
3
2
1
1
1
1
1
1
1
2
1
2
3
3
ST - Step Therapy
PA** - PA Applies if
115
Drug Name
Drug Tier Requirements/Limits
Ophthalmic Decongestants
naphazoline hcl ophth soln 0.1%
phenylephrine hcl ophth soln 2.5%
phenylephrine hcl ophth soln 10%
1
1
1
Ophthalmic Immunomodulators
RESTASIS EMU 0.05%
3
Ophthalmic Local Anesthetics
parcaine sol 0.5% op
proparacaine hcl ophth soln 0.5%
1
1
Ophthalmic Steroids
ALREX SUS 0.2%
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
BLEPHAMIDE OIN S.O.P.
BLEPHAMIDE SUS OP
dexamethasone sodium phosphate ophth
soln 0.1%
DUREZOL EMU 0.05%
FLAREX SUS 0.1% OP
fluor-op sus 0.1% op
fluorometholone ophth susp 0.1%
FML FORTE SUS 0.25% OP
FML OIN 0.1% OP
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
MAXIDEX SUS 0.1% OP
neo-polycin oin hc 1%op
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
neomycin-polymyxin-dexamethasone
ophth susp 0.1%
neomycin-polymyxin-hc ophth susp
poly-dex oin 0.1% op
PRED MILD SUS 0.12% OP
PRED SOD PHO SOL 1% OP
prednisolone acetate ophth susp 1%
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
tobramycin-dexamethasone ophth susp
0.3-0.1%
VEXOL SUS 1% OP
3
1
2
2
1
3
3
1
1
3
3
3
3
3
3
1
1
1
1
1
2
2
1
1
2
1
3
Ophthalmics - Misc.
ALAMAST DRO 0.1%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
ST - Step Therapy
PA** - PA Applies if
116
Drug Name
Drug Tier Requirements/Limits
ALOCRIL SOL 2%
3
ALOMIDE SOL 0.1% OP
3
azelastine hcl ophth soln 0.05%
1
AZOPT SUS 1% OP
3
BEPREVE DRO 1.5%
3
bromfenac sodium ophth soln 0.09% (base 1
equiv) (once-daily)
bromfenac sodium ophth soln 0.09% (base 1
equivalent)
cromolyn sodium ophth soln 4%
1
diclofenac sodium ophth soln 0.1%
1
dorzolamide hcl ophth soln 2%
1
EMADINE SOL 0.05% OP
3
epinastine hcl ophth soln 0.05%
1
flurbiprofen sodium ophth soln 0.03%
1
ketorolac tromethamine ophth soln 0.4% 1
ketorolac tromethamine ophth soln 0.5% 1
ketotifen fumarate ophth soln 0.025%
1
(base equiv)
LASTACAFT SOL 0.25%
3
NEVANAC SUS 0.1%
3
PATADAY SOL 0.2%
3
PATANOL SOL 0.1% OP
3
Prostaglandins - Ophthalmic
latanoprost ophth soln 0.005%
LUMIGAN SOL 0.01%
LUMIGAN SOL 0.03%
TRAVATAN Z DRO 0.004%
ZIOPTAN DRO 0.0015%
1
3
3
3
3
ST
ST
ST
ST
OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid 2% in aluminum acetate otic
soln
acetic acid otic soln 2%
1
1
Otic Anti-infectives
ofloxacin otic soln 0.3%
1
Otic Combinations
CIPRO HC SUS OTIC
CIPRODEX SUS 0.3-0.1%
CORTISPORIN SUS -TC OTIC
cortomycin sol 1% otic
cortomycin sus 1% otic
neomycin-polymyxin-hc otic soln 1%
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
2
3
1
1
1
ST - Step Therapy
PA** - PA Applies if
117
Drug Name
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
Drug Tier Requirements/Limits
1
Otic Steroids
fluocinolone acetonide (otic) oil 0.01%
hydrocortisone w/ acetic acid otic soln 12%
1
1
PASSIVE IMMUNIZING AGENTS
Immune Serums
CARIMUNE NF INJ 3GM
CARIMUNE NF INJ 6GM
CARIMUNE NF INJ 12GM
FLEBOGAMMA INJ 5%
FLEBOGAMMA INJ 10%
FLEBOGAMMA INJ DIF 5%
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ 5GM/50ML
GAMMAGARD INJ 10GM/100
GAMMAGARD INJ 20GM/200
GAMMAGARD INJ 30GM/300
GAMMAGARD SD INJ 2.5GM HU
GAMMAGARD SD INJ 5GM HU
GAMMAGARD SD INJ 10GM HU
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 5GM/50ML
GAMMAKED INJ 10GM/100
GAMMAKED INJ 20GM/200
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMMAPLEX INJ 10GM
GAMUNEX INJ 10%
GAMUNEX-C INJ 2.5GM/25
GAMUNEX-C INJ 5GM/50ML
GAMUNEX-C INJ 10GM/100
GAMUNEX-C INJ 20GM/200
HIZENTRA INJ 1GM/5ML
HIZENTRA INJ 2GM/10ML
HIZENTRA INJ 4GM/20ML
HIZENTRA INJ 10/50ML
OCTAGAM INJ 1GM
OCTAGAM INJ 5GM
OCTAGAM INJ 10GM
OCTAGAM INJ 25GM
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA** - PA Applies if
118
Drug Name
PRIVIGEN INJ
PRIVIGEN INJ
PRIVIGEN INJ
PRIVIGEN INJ
Drug Tier Requirements/Limits
4
PA
4
PA
4
PA
4
PA
5 GRAMS
10GRAMS
20GRAMS
40GRAMS
PENICILLINS
Aminopenicillins
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) chew tab 125 mg
amoxicillin (trihydrate) chew tab 200 mg
amoxicillin (trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for susp 125
mg/5ml
amoxicillin (trihydrate) for susp 200
mg/5ml
amoxicillin (trihydrate) for susp 250
mg/5ml
amoxicillin (trihydrate) for susp 400
mg/5ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
ampicillin sodium for inj 1 gm
ampicillin sodium for inj 2 gm
ampicillin sodium for inj 10 gm
ampicillin sodium for inj 125 mg
ampicillin sodium for inj 250 mg
ampicillin sodium for inj 500 mg
ampicillin sodium for iv soln 1 gm
ampicillin sodium for iv soln 2 gm
ampicillin sodium for iv soln 10 gm
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Extended-Spectrum Penicillins
PIPERACILLIN INJ 2GM
PIPERACILLIN INJ 4GM
PIPERACILLIN INJ 40GM
3
3
3
Natural Penicillins
BICILLIN L-A INJ 600000
BICILLIN L-A INJ 1200000
BICILLIN L-A INJ 2400000
PEN G PROC INJ 600000
PENICILL GK/ INJ DEX 1MU
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
3
3
3
3
3
ST - Step Therapy
PA** - PA Applies if
119
Drug Name
Drug Tier Requirements/Limits
PENICILL GK/ INJ DEX 2MU
3
PENICILL GK/ INJ DEX 3MU
3
penicillin g potassium for inj 5000000 unit 1
penicillin g potassium for inj 20000000 unit1
penicillin g sodium for inj 5000000 unit
1
penicillin v potassium for soln 125 mg/5ml 1
penicillin v potassium for soln 250 mg/5ml 1
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
pfizerpen-g inj 20mu
1
Penicillin Combinations
amoxicillin & k clavulanate chew tab 200- 1
28.5 mg
amoxicillin & k clavulanate chew tab 400- 1
57 mg
amoxicillin & k clavulanate for susp 2001
28.5 mg/5ml
amoxicillin & k clavulanate for susp 2501
62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 1
mg/5ml
amoxicillin & k clavulanate for susp 6001
42.9 mg/5ml
amoxicillin & k clavulanate tab 250-125 mg1
amoxicillin & k clavulanate tab 500-125 mg1
amoxicillin & k clavulanate tab 875-125 mg1
amoxicillin & k clavulanate tab sr 12hr
1
1000-62.5 mg
ampicillin & sulbactam sodium for inj 1-0.5 1
gm
ampicillin & sulbactam sodium for inj 2-1 1
gm
ampicillin & sulbactam sodium for inj 10-5 1
gm
ampicillin & sulbactam sodium for iv soln 1
1-0.5 gm
ampicillin & sulbactam sodium for iv soln 1
2-1 gm
ampicillin & sulbactam sodium for iv soln 1
10-5 gm
AUGMENTIN SUS 125/5ML
2
BICILLIN C-R INJ 900/300
3
BICILLIN C-R INJ 1200000
3
piperacillin sodium-tazobactam sodium for 1
inj 2-0.25 gm
piperacillin sodium-tazobactam sodium for 1
inj 3-0.375 gm
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
120
Drug Name
Drug Tier Requirements/Limits
piperacillin sodium-tazobactam sodium for 1
inj 4-0.5 gm
piperacillin sodium-tazobactam sodium for 1
inj 36-4.5 gm
TIMENTIN INJ 3.1GM
3
ZOSYN SOL 2-0.25GM
3
ZOSYN SOL 3-0.375G
3
ZOSYN SOL 4-0.50GM
3
Penicillinase-Resistant Penicillins
BACTOCILL INJ DEX 1GM
BACTOCILL INJ DEX 2GM
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
nafcillin sodium for inj 1 gm
nafcillin sodium for inj 2 gm
nafcillin sodium for inj 10 gm
nafcillin sodium for iv soln 1 gm
nafcillin sodium for iv soln 2 gm
NALLPEN/DEX INJ 1GM/50ML
NALLPEN/DEX INJ 2GM/100
oxacillin sodium for inj 1 gm
oxacillin sodium for inj 2 gm
oxacillin sodium for inj 10 gm
3
3
1
1
1
1
1
1
1
3
3
1
1
1
PROGESTINS
Progestins
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
medroxyprogesterone acetate tab 10 mg
MEGACE ES SUS 625/5ML
norethindrone acetate tab 5 mg
progesterone micronized cap 100 mg
progesterone micronized cap 200 mg
1
1
1
3
1
1
1
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Chemical Dependency
acamprosate calcium tab delayed release
333 mg
CAMPRAL TAB 333MG
disulfiram tab 250 mg
disulfiram tab 500 mg
1
PA
3
1
1
PA
2
PA
Anti-Cataplectic Agents
XYREM SOL 500MG/ML
Antidementia Agents
donepezil hydrochloride orally
disintegrating tab 5 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA** - PA Applies if
121
Drug Name
donepezil hydrochloride orally
disintegrating tab 10 mg
donepezil hydrochloride tab 5 mg
donepezil hydrochloride tab 10 mg
donepezil hydrochloride tab 23 mg
EXELON DIS 4.6MG/24
EXELON DIS 9.5MG/24
EXELON DIS 13.3/24
EXELON SOL 2MG/ML
galantamine hydrobromide cap sr 24hr 8
mg
galantamine hydrobromide cap sr 24hr 16
mg
galantamine hydrobromide cap sr 24hr 24
mg
galantamine hydrobromide oral soln 4
mg/ml
galantamine hydrobromide tab 4 mg
galantamine hydrobromide tab 8 mg
galantamine hydrobromide tab 12 mg
NAMENDA SOL 10MG/5ML
NAMENDA TAB 5-10MG
NAMENDA TAB 5MG
NAMENDA TAB 10MG
rivastigmine tartrate cap 1.5 mg
rivastigmine tartrate cap 3 mg
rivastigmine tartrate cap 4.5 mg
rivastigmine tartrate cap 6 mg
Drug Tier Requirements/Limits
1
1
1
1
3
3
3
2
1
PA
PA
PA
PA
1
1
1
1
1
1
2
3
2
2
1
1
1
1
PA
PA
PA
PA
Fibromyalgia Agents
SAVELLA
SAVELLA
SAVELLA
SAVELLA
SAVELLA
MIS
TAB
TAB
TAB
TAB
TITR PAK
12.5MG
25MG
50MG
100MG
3
3
3
3
3
Movement Disorder Drug Therapy
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
4
4
PA
PA
4
4
4
4
4
4
4
PA
PA, ST
PA, ST
PA
PA
PA
PA, ST
Multiple Sclerosis Agents
AMPYRA TAB 10MG
AUBAGIO TAB 7MG
AUBAGIO TAB 14MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
BETASERON INJ 0.3MG
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
122
Drug Name
COPAXONE INJ 40MG/ML
COPAXONE KIT 20MG/ML
EXTAVIA INJ 0.3MG
GILENYA CAP 0.5MG
REBIF INJ 22/0.5
REBIF INJ 44/0.5
REBIF TITRTN SOL PACK
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
TYSABRI INJ 300/15ML
Drug Tier Requirements/Limits
4
PA
4
PA
4
PA
4
PA
4
PA, ST
4
PA, ST
4
PA, ST
4
PA
4
PA
4
PA, ST
Postherpetic Neuralgia (PHN) Agents
GRALISE STAR MIS 300/600
GRALISE TAB 300MG
GRALISE TAB 600MG
3
3
3
ST; PA**
ST; PA**
ST; PA**
Pseudobulbar Affect (PBA) Agents
NUEDEXTA CAP 20-10MG
3
Psychotherapeutic and Neurological Agents - Misc.
ergoloid mesylates tab 1 mg
ORAP TAB 1MG
ORAP TAB 2MG
1
3
3
Restless Leg Syndrome (RLS) Agents
HORIZANT TAB 300MG
HORIZANT TAB 600MG
3
3
ST; PA**
ST; PA**
buproban tab 150mg
0
bupropion hcl (smoking deterrent) tab sr
12hr 150 mg
0
CHANTIX PAK 0.5& 1MG
0
CHANTIX PAK 1MG
0
CHANTIX TAB 0.5MG
0
CHANTIX TAB 1MG
0
nicotine polacrilex gum 2 mg
0
nicotine polacrilex gum 4 mg
0
nicotine polacrilex lozenge 2 mg
0
$0 limited to 2
treatment cycles/year
$0 limited to 2
treatment cycles/year
$0 limited to 2
treatment cycles/year
$0 limited to 2
treatment cycles/year
$0 limited to 2
treatment cycles/year
$0 limited to 2
treatment cycles/year
OTC; $0 limited to 2
treatment cycles/year
OTC; $0 limited to 2
treatment cycles/year
OTC; $0 limited to 2
treatment cycles/year
Smoking Deterrents
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
123
Drug Name
nicotine polacrilex lozenge 4 mg
Drug Tier Requirements/Limits
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
3
ST
3
ST
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
0
OTC; $0 limited to 2
treatment cycles/year
nicotine td patch 24hr 7 mg/24hr
nicotine td patch 24hr 14 mg/24hr
nicotine td patch 24hr 21 mg/24hr
NICOTROL INH
NICOTROL NS SPR 10MG/ML
sm nicotine dis 7mg/24hr
sm nicotine dis 14mg/24h
sm nicotine dis 21mg
thrive gum 4mg mint
RESPIRATORY AGENTS - MISC.
Alpha-Proteinase Inhibitor (Human)
ARALAST NP INJ 400MG
ARALAST NP INJ 500MG
ARALAST NP INJ 800MG
GLASSIA INJ
PROLASTIN INJ 500MG
PROLASTIN INJ 1000MG
PROLASTIN-C INJ 1000MG
ZEMAIRA INJ 1000MG
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
PA
4
PA
Cystic Fibrosis Agents
KALYDECO TAB 150MG
SULFONAMIDES
Sulfonamides
SULFADIAZINE TAB 500MG
3
TETRACYCLINES
Tetracyclines
avidoxy tab 100mg
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxy 100 inj 100mg
DOXYCYCL HYC CAP 100MG
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
3
1
1
ST - Step Therapy
PA** - PA Applies if
124
Drug Name
Drug Tier Requirements/Limits
doxycycline hyclate for inj 100 mg
1
doxycycline hyclate tab 20 mg
1
doxycycline hyclate tab 100 mg
1
doxycycline hyclate tab delayed release 75 1
mg
doxycycline hyclate tab delayed release
1
100 mg
doxycycline hyclate tab delayed release
1
150 mg
doxycycline monohydrate cap 50 mg
1
doxycycline monohydrate cap 75 mg
1
doxycycline monohydrate cap 100 mg
1
doxycycline monohydrate cap 150 mg
1
doxycycline monohydrate for susp 25
1
mg/5ml
doxycycline monohydrate tab 50 mg
1
doxycycline monohydrate tab 75 mg
1
doxycycline monohydrate tab 150 mg
1
minocycline hcl cap 50 mg
1
minocycline hcl cap 75 mg
1
minocycline hcl cap 100 mg
1
minocycline hcl tab 50 mg
1
minocycline hcl tab 75 mg
1
minocycline hcl tab 100 mg
1
minocycline hcl tab sr 24hr 45 mg
1
minocycline hcl tab sr 24hr 90 mg
1
minocycline hcl tab sr 24hr 135 mg
1
morgidox cap 1x100mg
1
tetracycline hcl cap 250 mg
1
tetracycline hcl cap 500 mg
1
VIBRAMYCIN SYP 50MG/5ML
3
THYROID AGENTS
Antithyroid Agents
methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
1
1
1
Thyroid Hormones
levothroid
levothroid
levothroid
levothroid
levothroid
levothroid
levothroid
tab
tab
tab
tab
tab
tab
tab
25mcg
50mcg
75mcg
88mcg
100mcg
112mcg
125mcg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
125
Drug Name
levothroid tab 137mcg
levothroid tab 150mcg
levothroid tab 175mcg
levothroid tab 200mcg
levothroid tab 300mcg
levothyroxine sodium tab 25 mcg
levothyroxine sodium tab 50 mcg
levothyroxine sodium tab 75 mcg
levothyroxine sodium tab 88 mcg
levothyroxine sodium tab 100 mcg
levothyroxine sodium tab 112 mcg
levothyroxine sodium tab 125 mcg
levothyroxine sodium tab 137 mcg
levothyroxine sodium tab 150 mcg
levothyroxine sodium tab 175 mcg
levothyroxine sodium tab 200 mcg
levothyroxine sodium tab 300 mcg
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
liothyronine sodium iv soln 10 mcg/ml
liothyronine sodium tab 5 mcg
liothyronine sodium tab 25 mcg
liothyronine sodium tab 50 mcg
THYROLAR-1 TAB 60MG
THYROLAR-1/2 TAB 30MG
THYROLAR-1/4 TAB 15MG
THYROLAR-2 TAB 120MG
THYROLAR-3 TAB 180MG
unithroid tab 25mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
1
1
1
1
1
1
1
ST - Step Therapy
PA** - PA Applies if
126
Drug Name
unithroid tab
unithroid tab
unithroid tab
unithroid tab
unithroid tab
137mcg
150mcg
175mcg
200mcg
300mcg
Drug Tier Requirements/Limits
1
1
1
1
1
TOXOIDS
Toxoid Combinations
ADACEL INJ
BOOSTRIX INJ
DAPTACEL INJ
DECAVAC INJ 5-2LF
DIP/TET PED INJ 6.7-5LF
DIP/TET PED INJ 25-5LFU
INFANRIX INJ
KINRIX INJ
PEDIARIX INJ 0.5ML
PENTACEL INJ
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TRIHIBIT KIT P/F
TRIPEDIA SUS P/F
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Toxoids
TETANUS TOX INJ 5LF ADS
0
ULCER DRUGS
Antispasmodics
ATROPEN INJ 0.5MG
3
ATROPEN INJ 0.25MG
3
ATROPEN INJ 1MG
3
ATROPEN INJ 2MG
3
atropine sulfate inj 0.1 mg/ml
1
atropine sulfate inj 0.4 mg/ml
1
atropine sulfate inj 0.8 mg/ml
1
atropine sulfate inj 0.05 mg/ml
1
atropine sulfate inj 1 mg/ml
1
BENTYL INJ 10MG/ML
3
CANTIL TAB 25MG
3
clidinium & chlordiazepoxide cap 2.5-5 mg 1
CUVPOSA SOL 1MG/5ML
2
dicyclomine hcl cap 10 mg
1
dicyclomine hcl oral soln 10 mg/5ml
1
dicyclomine hcl tab 20 mg
1
ed-spaz tab 0.125mg
1
glycopyrrolate inj 0.2 mg/ml
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
127
Drug Name
glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)
glycopyrrolate inj 1 mg/5ml (0.2 mg/ml)
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
hyomax tab 0.125mg
hyomax-ft tab 0.125mg
hyomax-sl sub 0.125mg
hyomax-sr tab 0.375mg
hyoscyamine sulfate tab 0.125 mg
hyoscyamine sulfate tab disp 0.125 mg
hyoscyamine sulfate tab sl 0.125 mg
hyoscyamine sulfate tab sr 12hr 0.375 mg
methscopolamine bromide tab 2.5 mg
methscopolamine bromide tab 5 mg
nulev tab 0.125mg
oscimin sr tab 0.375mg
oscimin sub 0.125mg
oscimin tab 0.125mg
symax fastab tab 0.125mg
symax-sl sub 0.125mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
H-2 Antagonists
cimetidine hcl soln 300 mg/5ml
1
cimetidine tab 200 mg
1
cimetidine tab 300 mg
1
cimetidine tab 400 mg
1
cimetidine tab 800 mg
1
famotidine for susp 40 mg/5ml
1
famotidine in nacl 0.9% iv soln 20
1
mg/50ml
famotidine inj 40 mg/4ml
1
famotidine tab 20 mg
1
famotidine tab 40 mg
1
nizatidine cap 150 mg
1
nizatidine cap 300 mg
1
nizatidine oral soln 15 mg/ml
1
ranitidine hcl cap 150 mg
1
ranitidine hcl cap 300 mg
1
ranitidine hcl inj 50 mg/2ml (25 mg/ml)
1
ranitidine hcl inj 150 mg/6ml (25 mg/ml) 1
ranitidine hcl inj 1000 mg/40ml (25
1
mg/ml)
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1
ranitidine hcl tab 150 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
PA** - PA Applies if
128
Drug Name
ranitidine hcl tab 300 mg
ZANTAC INJ 50/50ML
ZANTAC TAB 25MG EF
Drug Tier Requirements/Limits
1
3
3
Misc. Anti-Ulcer
CARAFATE SUS 1GM/10ML
sucralfate tab 1 gm
3
1
Proton Pump Inhibitors
DEXILANT CAP 30MG DR
3
DEXILANT CAP 60MG DR
3
esomeprazole sodium for intravenous soln 1
20 mg (base equiv)
esomeprazole sodium for intravenous soln 1
40 mg (base equiv)
lansoprazole cap delayed release 15 mg
1
lansoprazole cap delayed release 30 mg
1
NEXIUM CAP 20MG
3
NEXIUM CAP 40MG
3
NEXIUM GRA 2.5MG DR
3
NEXIUM GRA 5MG DR
3
NEXIUM GRA 10MG DR
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole cap delayed release 10 mg
1
omeprazole cap delayed release 20 mg
1
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
QL (30 caps / 25 days;
90 max in 365 days), ST
QL (30 caps / 25 days;
90 max in 365 days), ST
QL (30 caps / 25 days;
90 max in 365 days)
QL (30 caps / 25 days;
90 max in 365 days)
QL (30 caps / 25 days;
90 max in 365 days), ST
QL (30 caps / 25 days;
90 max in 365 days), ST
QL (30 packets / 25
days; 90 max in 365
days), ST
QL (30 packets / 25
days; 90 max in 365
days), ST
QL (30 packets / 25
days; 90 max in 365
days), ST
QL (30 packets / 25
days; 90 max in 365
days), ST
QL (30 packets / 25
days; 90 max in 365
days), ST
QL (30 caps / 25 days;
90 max in 365 days)
QL (30 caps / 25 days;
90 max in 365 days)
PA** - PA Applies if
129
Drug Name
omeprazole cap delayed release 40 mg
pantoprazole sodium ec tab 20 mg (base
equiv)
pantoprazole sodium ec tab 40 mg (base
equiv)
PROTONIX PAK
rabeprazole sodium ec tab 20 mg
Drug Tier Requirements/Limits
1
QL (30 caps / 25 days;
90 max in 365 days)
1
QL (30 tabs / 25 days;
90 max in 365 days)
1
QL (30 tabs / 25 days;
90 max in 365 days)
3
QL (30 packets / 25
days; 90 max in 365
days)
1
QL (30 tabs / 25 days;
90 max in 365 days)
Ulcer Drugs - Prostaglandins
misoprostol tab 100 mcg
misoprostol tab 200 mcg
1
1
Ulcer Therapy Combinations
omeprazole-sodium bicarbonate cap 201100 mg
omeprazole-sodium bicarbonate cap 401100 mg
1
QL (30 caps / 25 days)
1
QL (30 caps / 25 days)
2
PA; High Risk
Medications require PA
for members age 65 and
older
URINARY ANTI-INFECTIVES
Urinary Anti-infectives
MACRODANTIN CAP 25MG
methenamine hippurate tab 1 gm
1
MONUROL PAK GRANULES
3
nitrofurantoin macrocrystalline cap 50 mg 1
nitrofurantoin macrocrystalline cap 100 mg 1
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
1
ST - Step Therapy
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA** - PA Applies if
130
Drug Name
nitrofurantoin susp 25 mg/5ml
Drug Tier Requirements/Limits
1
PA; High Risk
Medications require PA
for members age 65 and
older
URINARY ANTISPASMODICS
Beta-3 Adrenergic Agonists
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
3
3
ST
ST
Urinary Antispasmodics
bethanechol chloride tab 5 mg
bethanechol chloride tab 10 mg
bethanechol chloride tab 25 mg
bethanechol chloride tab 50 mg
ENABLEX TAB 7.5MG
ENABLEX TAB 15MG
flavoxate hcl tab 100 mg
GELNIQUE GEL 3%
GELNIQUE GEL 10%
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 5 mg
oxybutynin chloride tab sr 24hr 10 mg
oxybutynin chloride tab sr 24hr 15 mg
OXYTROL DIS 3.9MG/24
tolterodine tartrate cap sr 24hr 2 mg
tolterodine tartrate cap sr 24hr 4 mg
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chloride cap sr 24hr 60 mg
trospium chloride tab 20 mg
VESICARE TAB 5MG
VESICARE TAB 10MG
1
1
1
1
3
3
1
3
3
1
1
1
1
1
3
1
1
1
1
3
3
1
1
3
3
ST
ST
ST
ST
ST
ST
ST
ST
ST
VACCINES
Bacterial Vaccines
ACTHIB INJ
HIBERIX SOL 10-25MCG
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
0
0
0
0
0
0
ST - Step Therapy
PA** - PA Applies if
131
Drug Name
PEDVAX HIB INJ
PNEUMOVAX 23 INJ 25/0.5
PREVNAR 13 INJ
Drug Tier Requirements/Limits
0
0
0
Mixed Vaccine Combinations
COMVAX INJ
0
Viral Vaccines
AFLURIA INJ 2012-13
AFLURIA INJ 2013-14
AFLURIA INJ PF 10-11
AFLURIA INJ PF 11-12
AFLURIA INJ PF 12-13
AGRIFLU INJ PF 10-11
CERVARIX INJ
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
EZ FLU SHOT KIT 13-14
EZ FLU SHOT KIT PF 13-14
EZ USE FLU KIT 2012-13
FLUARIX INJ PF 11-12
FLUARIX INJ PF 12-13
FLUARIX PF INJ 2013-14
FLUBLOK SOL 2013-14
FLUCELVAX INJ 2012-13
FLUCELVAX INJ 2013-14
FLULAVAL INJ 2011-12
FLULAVAL INJ 2012-13
FLULAVAL QUA INJ 2013-14
FLUMIST NASA LIQ 2011-12
FLUMIST NASA LIQ 2012-13
FLUMIST QUAD SUS 2013-14
FLUVIRIN INJ 2012-13
FLUVIRIN INJ 2013-14
FLUVIRIN INJ PF 11-12
FLUVIRIN INJ PF 12-13
FLUZONE HD INJ PF 11-12
FLUZONE HD INJ PF 12-13
FLUZONE HD INJ PF 13-14
FLUZONE INJ INTRADRM
FLUZONE INJ PF 11-12
FLUZONE INJ PF 12-13
FLUZONE PED/ INJ PF 11-12
FLUZONE PED/ INJ PF 12-13
FLUZONE QUAD INJ 13-14
FLUZONE SPLT INJ 2013-14
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ST - Step Therapy
PA** - PA Applies if
132
Drug Name
GARDASIL INJ
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
INFLUENZA A SPR 09 H1N1
IPOL INJ INACTIVE
M-M-R II INJ LIVE
PROQUAD INJ
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
TWINRIX INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
ZOSTAVAX INJ
Drug Tier Requirements/Limits
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
VAGINAL PRODUCTS
Spermicides
CONCEPTROL GEL 4%
ENCARE SUP 100MG
GYNOL II GEL 3%
SHUR-SEAL GEL 2%
VCF VAGINAL AER CONTRACP
VCF VAGINAL MIS CONTRACP
0
0
0
0
0
0
OTC
OTC
OTC
OTC
OTC
OTC
Vaginal Anti-infectives
CLEOCIN SUP 100MG
clindamycin phosphate vaginal cream 2%
GYNAZOLE-1 CRE 2%
metronidazole vaginal gel 0.75%
miconazole 3 sup 200mg
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
terconazole vaginal suppos 80 mg
vandazole gel 0.75%
zazole cre 0.4%
zazole cre 0.8%
zazole sup 80mg
2
1
3
1
1
1
1
1
1
1
1
1
Vaginal Estrogens
ESTRACE VAG CRE 0.1MG/GM
ESTRING MIS 2MG
FEMRING MIS 0.1MG/24
FEMRING MIS 0.05/24H
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
2
3
3
3
ST - Step Therapy
PA** - PA Applies if
133
Drug Name
PREMARIN VAG CRE 0.625MG
VAGIFEM TAB 10MCG
Drug Tier Requirements/Limits
3
3
Vaginal Progestins
CRINONE GEL 4% VAG
CRINONE GEL 8% VAG
2
2
VASOPRESSORS
Anaphylaxis Therapy Agents
epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)
epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)
EPIPEN 2-PAK INJ 0.3MG
EPIPEN INJ 0.3MG
EPIPEN-JR INJ 0.15MG
EPIPEN-JR INJ 2-PAK
1
1
2
2
2
2
Vasopressors
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
1
1
1
VITAMINS
Oil Soluble Vitamins
bio-d-mulsio liq 400unit
0
child vit d chw 400unit
0
ergocalciferol cap 50000 unit
MEPHYTON TAB 5MG
pedia d-vite dro 400unit
1
2
0
sm vitamin d tab 400unit
0
VITAMIN D2 TAB 400UNIT
0
VITAMIN D3 CAP 400UNIT
0
VITAMIN D3 LIQ 1000UNIT
0
PA - Prior Authorization QL - Quantity Limits
Step is Not Met OTC - Over the Counter
ST - Step Therapy
OTC; $0 applies for ages
65 and older
OTC; $0 applies for ages
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
for ages
for ages
for ages
for ages
for ages
PA** - PA Applies if
134
Index
8
8-MOP CAP 10MG
84
A
a-hydrocort inj 100mg
76
a-methapred inj 125mg
76
a-methapred inj 40mg
76
abacavir sulfate tab 300 mg (base
equiv)
60
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
60
ABELCET INJ 5MG/ML
39
ABILIFY DISC TAB 10MG
60
ABILIFY DISC TAB 15MG
60
ABILIFY INJ 9.75MG
60
ABILIFY SOL 1MG/ML
60
ABILIFY TAB 10MG
60
ABILIFY TAB 15MG
60
ABILIFY TAB 20MG
60
ABILIFY TAB 2MG
60
ABILIFY TAB 30MG
60
ABILIFY TAB 5MG
60
ABRAXANE INJ 100MG
54
ABSTRAL SUB 100MCG
7
ABSTRAL SUB 200MCG
7
ABSTRAL SUB 300MCG
7
ABSTRAL SUB 400MCG
8
ABSTRAL SUB 600MCG
8
ABSTRAL SUB 800MCG
8
acamprosate calcium tab delayed release
333 mg
121
ACANYA GEL 1.2-2.5%
78
acarbose tab 100 mg
33
acarbose tab 25 mg
33
acarbose tab 50 mg
33
ACCU-CHEK BLOOD GLUCOSE TEST
KITS
107
ACCU-CHEK BLOOD GLUCOSE TEST
STRIPS
107
acd/fluoride dro 0.25mg
111
acebutolol hcl cap 200 mg
65
acebutolol hcl cap 400 mg
65
acetaminophen w/ codeine soln 120-12
mg/5ml
12
acetaminophen w/ codeine tab 300-15
mg
12
acetaminophen w/ codeine tab 300-30
mg
12
acetaminophen w/ codeine tab 300-60
mg
12
acetazolamide cap sr 12hr 500 mg
88
acetazolamide sodium for inj 500 mg
88
acetazolamide tab 125 mg
88
acetazolamide tab 250 mg
88
acetic acid 2% in aluminum acetate otic
soln
117
acetic acid otic soln 2%
117
acetylcysteine inhal soln 10%
78
acetylcysteine inhal soln 20%
78
acitretin cap 10 mg
83
acitretin cap 17.5 mg
83
acitretin cap 25 mg
83
ACTEMRA INJ 162/0.9
5
ACTEMRA INJ 200/10ML
5
ACTEMRA INJ 400/20ML
5
ACTEMRA INJ 80MG/4ML
5
ACTHIB INJ
131
acticin cre 5%
87
ACTIMMUNE INJ 2MU/0.5
53
ACTONEL TAB 150MG
90
ACTONEL TAB 30MG
90
ACTONEL TAB 35MG
90
ACTONEL TAB 5MG
90
acyclovir cap 200 mg
63
acyclovir oint 5%
84
acyclovir sodium for inj 1000 mg
63
acyclovir sodium for inj 500 mg
63
acyclovir susp 200 mg/5ml
63
acyclovir tab 400 mg
63
acyclovir tab 800 mg
63
ADACEL INJ
127
ADAGEN INJ 250/ML
67
adapalene cream 0.1%
78
adapalene gel 0.1%
78
ADCIRCA TAB 20MG
70
adefovir dipivoxil tab 10 mg
62
adriamycin inj 10mg
51
ADRIAMYCIN INJ 20MG
51
adrucil inj 500/10ml
49
ADULT ASA TAB 81MG QM
7
ADVAIR DISKU AER 100/50
21
afeditab tab 30mg cr
67
afeditab tab 60mg cr
67
AFINITOR TAB 10MG
52
AFINITOR TAB 2.5MG
52
AFINITOR TAB 5MG
52
AFINITOR TAB 7.5MG
52
AFLURIA INJ 2012-13
132
AFLURIA INJ 2013-14
132
AFLURIA INJ PF 10-11
132
AFLURIA INJ PF 11-12
132
AFLURIA INJ PF 12-13
132
AGGRENOX CAP 25-200MG
101
AGRIFLU INJ PF 10-11
132
ala cort cre 1%
84
ALAMAST DRO 0.1%
116
ALBENZA TAB 200MG
14
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml)
21
albuterol sulfate soln nebu 0.5% (5
mg/ml)
21
albuterol sulfate soln nebu 0.63 mg/3ml
(base equiv)
21
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv)
21
albuterol sulfate syrup 2 mg/5ml
21
albuterol sulfate tab 2 mg
21
135
albuterol sulfate tab 4 mg
21
albuterol sulfate tab sr 12hr 4 mg
21
albuterol sulfate tab sr 12hr 8 mg
21
alclometasone dipropionate cream
0.05%
84
alclometasone dipropionate oint 0.05% 84
ALCOHOL PREP WIPES AND SWABS
107
ALDACTAZIDE TAB 50/50
88
ALDURAZYME INJ 2.9MG/5M
92
alendronate sodium tab 10 mg
90
alendronate sodium tab 35 mg
90
alendronate sodium tab 40 mg
90
alendronate sodium tab 5 mg
90
alendronate sodium tab 70 mg
90
ALFERON N INJ 5MU/ML
53
alfuzosin hcl tab sr 24hr 10 mg
100
ALIMTA INJ 100MG
49
ALIMTA INJ 500MG
49
ALINIA SUS 100/5ML
15
ALINIA TAB 500MG
15
ALKERAN TAB 2MG
48
ALLFEN CDX LIQ
78
allopurinol sodium for inj 500 mg
100
allopurinol tab 100 mg
100
allopurinol tab 300 mg
100
ALOCRIL SOL 2%
117
ALOMIDE SOL 0.1% OP
117
ALORA DIS 0.025MG
94
ALORA DIS 0.05MG
93
ALORA DIS 0.075MG
94
ALORA DIS 0.1MG
93
ALOXI INJ
38
ALOXI INJ 0.25MG/5
38
ALPHAGAN P SOL 0.1%
115
alphatrex gel 0.05%
84
ALPRAZOLAM CON 1 MG/ML
18
alprazolam orally disintegrating tab 0.25
mg
18
alprazolam orally disintegrating tab 0.5
mg
18
alprazolam orally disintegrating tab 1
mg
18
alprazolam orally disintegrating tab 2
mg
18
alprazolam tab 0.25 mg
18
alprazolam tab 0.5 mg
18
alprazolam tab 1 mg
18
alprazolam tab 2 mg
18
ALREX SUS 0.2%
116
ALTABAX OIN 1%
82
altavera tab
73
ALVESCO AER 160MCG
20
ALVESCO AER 80MCG
20
alyacen tab 1/35
73
alyacen tab 7/7/7
73
amantadine hcl cap 100 mg
55
amantadine hcl syrup 50 mg/5ml
55
amantadine hcl tab 100 mg
55
AMBISOME INJ 50MG
39
amcinonide cream 0.1%
84
amcinonide lotion 0.1%
84
AMCINONIDE OIN 0.1%
84
amethia tab
73
amethyst tab 90-20mcg
73
AMEVIVE INJ 15MG
83
amifostine crystalline for inj 500 mg
54
amikacin sulfate inj 1 gm/4ml (250
mg/ml)
4
amikacin sulfate inj 100 mg/2ml (50
mg/ml)
4
amikacin sulfate inj 500 mg/2ml (250
mg/ml)
4
amiloride & hydrochlorothiazide tab 5-50
mg
88
amiloride hcl tab 5 mg
89
aminophylline inj 25 mg/ml
22
amiodarone hcl inj 150 mg/3ml (50
mg/ml)
19
amiodarone hcl inj 450 mg/9ml (50
mg/ml)
19
amiodarone hcl inj 900 mg/18ml (50
mg/ml)
19
amiodarone hcl tab 200 mg
20
amiodarone hcl tab 400 mg
20
AMITIZA CAP 24MCG
99
AMITIZA CAP 8MCG
99
amitriptyline hcl tab 10 mg
30
amitriptyline hcl tab 100 mg
30
amitriptyline hcl tab 150 mg
30
amitriptyline hcl tab 25 mg
30
amitriptyline hcl tab 50 mg
30
amitriptyline hcl tab 75 mg
30
amlodipine besylate tab 10 mg
67
amlodipine besylate tab 2.5 mg
67
amlodipine besylate tab 5 mg
67
amlodipine besylate-benazepril hcl cap 1020 mg
45
amlodipine besylate-benazepril hcl cap 1040 mg
45
amlodipine besylate-benazepril hcl cap
2.5-10 mg
45
amlodipine besylate-benazepril hcl cap 510 mg
45
amlodipine besylate-benazepril hcl cap 520 mg
45
amlodipine besylate-benazepril hcl cap 540 mg
45
AMMONIUM CHL INJ 5MEQ/ML
108
amnesteem cap 10mg
79
amnesteem cap 20mg
79
amnesteem cap 40mg
79
amoxapine tab 100 mg
31
amoxapine tab 150 mg
31
amoxapine tab 25 mg
30
amoxapine tab 50 mg
30
amoxicillin & k clavulanate chew tab 20028.5 mg
120
amoxicillin & k clavulanate chew tab 40057 mg
120
amoxicillin & k clavulanate for susp 20028.5 mg/5ml
120
136
amoxicillin & k clavulanate for susp 25062.5 mg/5ml
120
amoxicillin & k clavulanate for susp 40057 mg/5ml
120
amoxicillin & k clavulanate for susp 60042.9 mg/5ml
120
amoxicillin & k clavulanate tab 250-125
mg
120
amoxicillin & k clavulanate tab 500-125
mg
120
amoxicillin & k clavulanate tab 875-125
mg
120
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg
120
amoxicillin (trihydrate) cap 250 mg
119
amoxicillin (trihydrate) cap 500 mg
119
amoxicillin (trihydrate) chew tab 125
mg
119
amoxicillin (trihydrate) chew tab 200
mg
119
amoxicillin (trihydrate) chew tab 250
mg
119
amoxicillin (trihydrate) for susp 125
mg/5ml
119
amoxicillin (trihydrate) for susp 200
mg/5ml
119
amoxicillin (trihydrate) for susp 250
mg/5ml
119
amoxicillin (trihydrate) for susp 400
mg/5ml
119
amoxicillin (trihydrate) tab 500 mg
119
amoxicillin (trihydrate) tab 875 mg
119
amphetamine-dextroamphetamine cap sr
24hr 10 mg
1
amphetamine-dextroamphetamine cap sr
24hr 15 mg
1
amphetamine-dextroamphetamine cap sr
24hr 20 mg
1
amphetamine-dextroamphetamine cap sr
24hr 25 mg
1
amphetamine-dextroamphetamine cap sr
24hr 30 mg
1
amphetamine-dextroamphetamine cap sr
24hr 5 mg
1
amphetamine-dextroamphetamine tab 10
mg
1
amphetamine-dextroamphetamine tab
12.5 mg
1
amphetamine-dextroamphetamine tab 15
mg
1
amphetamine-dextroamphetamine tab 20
mg
1
amphetamine-dextroamphetamine tab 30
mg
1
amphetamine-dextroamphetamine tab 5
mg
1
amphetamine-dextroamphetamine tab 7.5
mg
1
AMPHOTEC INJ 100MG
39
AMPHOTEC INJ 50MG
39
amphotericin b for inj 50 mg
39
ampicillin & sulbactam sodium for inj 1-0.5
gm
120
ampicillin & sulbactam sodium for inj 10-5
gm
120
ampicillin & sulbactam sodium for inj 2-1
gm
120
ampicillin & sulbactam sodium for iv soln
1-0.5 gm
120
ampicillin & sulbactam sodium for iv soln
10-5 gm
120
ampicillin & sulbactam sodium for iv soln
2-1 gm
120
ampicillin cap 250 mg
119
ampicillin cap 500 mg
119
ampicillin for susp 125 mg/5ml
119
ampicillin for susp 250 mg/5ml
119
ampicillin sodium for inj 1 gm
119
ampicillin sodium for inj 10 gm
119
ampicillin sodium for inj 125 mg
119
ampicillin sodium for inj 2 gm
119
ampicillin sodium for inj 250 mg
119
ampicillin sodium for inj 500 mg
119
ampicillin sodium for iv soln 1 gm
119
ampicillin sodium for iv soln 10 gm
119
ampicillin sodium for iv soln 2 gm
119
AMPYRA TAB 10MG
122
ANADROL-50 TAB 50MG
13
anagrelide hcl cap 0.5 mg
101
anagrelide hcl cap 1 mg
101
anastrozole tab 1 mg
50
ANDRODERM DIS 2.5MG/24
13
ANDRODERM DIS 2MG/24HR
13
ANDRODERM DIS 4MG/24HR
13
ANDRODERM DIS 5MG/24HR
13
android cap 10mg
13
ANDROXY TAB 10MG
13
anti-diarrhe tab 2mg
37
ANTIVERT TAB 50MG
38
anucort-hc sup 25mg
14
ANZEMET TAB 100MG
38
ANZEMET TAB 50MG
38
apexicon oin 0.05%
84
APHTHASOL PST 5%
111
APIDRA INJ SOLOSTAR
35
APIDRA INJ U-100
35
APLENZIN TAB 174MG
28
APLENZIN TAB 348MG
28
APLENZIN TAB 522MG
28
APOKYN INJ
55
apraclonidine hcl ophth soln 0.5% (base
equivalent)
115
apri tab
73
APRISO CAP 0.375GM
99
APTIVUS CAP 250MG
60
APTIVUS SOL
60
ARALAST NP INJ 400MG
124
ARALAST NP INJ 500MG
124
ARALAST NP INJ 800MG
124
aranelle tab
73
ARANESP INJ 100MCG
102
ARANESP INJ 150MCG
102
137
ARANESP INJ 200MCG
102
ARANESP INJ 25MCG
102
ARANESP INJ 300MCG
102
ARANESP INJ 40MCG
102
ARANESP INJ 500MCG
102
ARANESP INJ 60MCG
102
arbinoxa sol 4mg/5ml
40
ARCALYST INJ 220MG
5
ARCAPTA CAP 75MCG
21
argatroban inj 100 mg/ml (concentrate for
iv infusion)
24
ARGATROBAN INJ 125/125
24
ARRANON INJ 5MG/ML
49
ARZERRA CON 100/5ML
50
ARZERRA CON 1000/50
50
asmalpred sol plus
76
ASMANEX 120 AER 220MCG
20
ASMANEX 30 AER 110MCG
20
ASMANEX 30 AER 220MCG
20
ASMANEX 60 AER 220MCG
20
aspirin chew tab 81 mg
7
aspirin low tab 81mg ec
7
aspirin tab 325 mg
7
ASPIRIN TAB 81 MG
7
aspirin tab delayed release 325 mg
7
ASTEPRO SPR 0.15%
113
astramorph inj 1mg/2ml
8
astramorph inj 2mg/2ml
8
ATELVIA TAB
90
atenolol & chlorthalidone tab 100-25 mg45
atenolol & chlorthalidone tab 50-25 mg 45
atenolol tab 100 mg
65
atenolol tab 25 mg
65
atenolol tab 50 mg
65
ATGAM INJ 250MG
64
atorvastatin calcium tab 10 mg (base
equivalent)
42
atorvastatin calcium tab 20 mg (base
equivalent)
42
atorvastatin calcium tab 40 mg (base
equivalent)
42
atorvastatin calcium tab 80 mg (base
equivalent)
42
atovaquone-proguanil hcl tab 250-100
mg
47
atovaquone-proguanil hcl tab 62.5-25
mg
47
ATRALIN GEL 0.05%
79
ATRIPLA TAB
60
ATROPEN INJ 0.25MG
127
ATROPEN INJ 0.5MG
127
ATROPEN INJ 1MG
127
ATROPEN INJ 2MG
127
atropine sulfate inj 0.05 mg/ml
127
atropine sulfate inj 0.1 mg/ml
127
atropine sulfate inj 0.4 mg/ml
127
atropine sulfate inj 0.8 mg/ml
127
atropine sulfate inj 1 mg/ml
127
atropine sulfate ophth oint 1%
114
atropine sulfate ophth soln 1%
114
ATROVENT HFA AER 17MCG
20
AUBAGIO TAB 14MG
122
AUBAGIO TAB 7MG
122
AUGMENTIN SUS 125/5ML
120
AVANDIA TAB 2MG
35
AVANDIA TAB 4MG
35
AVANDIA TAB 8MG
35
AVAR GEL 10-5%
79
avar-e green cre 10-5%
79
AVELOX INJ
98
aviane tab
73
avidoxy tab 100mg
124
avita cre 0.025%
79
avita gel 0.025%
79
AVODART CAP 0.5MG
100
AVONEX KIT 30MCG
122
AVONEX PEN KIT 30MCG
122
AVONEX PREFL KIT 30MCG
122
AXERT TAB 12.5MG
107
AXERT TAB 6.25MG
107
AXIRON SOL 30MG/ACT
13
azacitidine for inj 100 mg
49
AZACTAM/DEX INJ 1GM
14
AZACTAM/DEX INJ 2GM
14
AZASAN TAB 100MG
64
AZASAN TAB 75 MG
64
AZASITE SOL 1%
115
azathioprine sodium for inj 100 mg
64
azathioprine tab 50 mg
64
azelastine hcl nasal spray 137 mcg/spray
(1 mg/ml)
113
azelastine hcl ophth soln 0.05%
117
AZELEX CRE 20%
79
AZILECT TAB 0.5MG
57
AZILECT TAB 1MG
57
azithromycin for susp 100 mg/5ml
105
azithromycin for susp 200 mg/5ml
105
azithromycin iv for soln 500 mg
105
azithromycin powd pack for susp 1 gm 105
azithromycin tab 250 mg
105
azithromycin tab 500 mg
105
azithromycin tab 600 mg
105
AZOPT SUS 1% OP
117
aztreonam for inj 1 gm
14
aztreonam for inj 2 gm
14
azurette tab 28 day
73
B
bacitracin ophth oint 500 unit/gm
115
bacitracin-polymyxin b ophth oint
115
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
116
baclofen tab 10 mg
112
baclofen tab 20 mg
112
BACTOCILL INJ DEX 1GM
121
BACTOCILL INJ DEX 2GM
121
BACTROBAN OIN NASAL 2%
113
balsalazide disodium cap 750 mg
99
BANZEL SUS 40MG/ML
24
BANZEL TAB 200MG
24
138
BANZEL TAB 400MG
24
BARACLUDE SOL .05MG/ML
62
BARACLUDE TAB 0.5MG
62
BARACLUDE TAB 1MG
62
baycadron elx 0.5/5ml
76
benazepril & hydrochlorothiazide tab 1012.5 mg
45
benazepril & hydrochlorothiazide tab 2012.5 mg
45
benazepril & hydrochlorothiazide tab 2025 mg
45
benazepril & hydrochlorothiazide tab 56.25 mg
45
benazepril hcl tab 10 mg
43
benazepril hcl tab 20 mg
43
benazepril hcl tab 40 mg
43
benazepril hcl tab 5 mg
43
BENICAR TAB 20MG
44
BENICAR TAB 40MG
44
BENICAR TAB 5MG
44
BENLYSTA INJ 120MG
65
BENLYSTA INJ 400MG
65
BENTYL INJ 10MG/ML
127
BENZAMYCIN GEL PAK
79
BENZASHAVE 5 CRE 5%
79
benzashave cre 10%
79
benzepro aer 5.3%
79
benzepro sc aer 9.8%
79
BENZIQ GEL 5.25%
79
BENZIQ LS GEL 2.75%
79
benziq wash liq 5.25%
79
benzonatate cap 100 mg
78
benzonatate cap 200 mg
78
benzoyl per kit 4% wash
79
benzoyl per kit 8% wash
79
benzoyl per liq 2.5%wash
79
benzoyl per liq 4% crem
79
benzoyl per liq 8% crem
79
benzoyl per lot 3%
79
benzoyl per lot 4%
79
benzoyl per lot 6%
79
benzoyl per lot 8%
79
benzoyl per lot 9%
79
benzoyl pero kit acne pck
79
benzoyl peroxide cleanser 4.25%
79
benzoyl peroxide cream 3.5%
79
benzoyl peroxide cream 5.5%
79
benzoyl peroxide cream 8.5%
79
benzoyl peroxide foam 5.3%
79
benzoyl peroxide foam 9.8%
79
benzoyl peroxide pad 3%
79
benzoyl peroxide pad 6%
79
benzoyl peroxide pad 9%
79
benzoyl peroxide-erythromycin gel 53%
80
benztropine mesylate inj 1 mg/ml
55
benztropine mesylate tab 0.5 mg
55
benztropine mesylate tab 1 mg
55
benztropine mesylate tab 2 mg
55
BEPREVE DRO 1.5%
117
BESIVANCE SUS 0.6%
115
betamethasone dipropionate augmented
cream 0.05%
84
betamethasone dipropionate augmented
lotion 0.05%
84
betamethasone dipropionate augmented
oint 0.05%
84
betamethasone dipropionate cream
0.05%
84
betamethasone dipropionate lotion
0.05%
84
betamethasone dipropionate oint 0.05% 84
betamethasone valerate aerosol foam
0.12%
84
betamethasone valerate cream 0.1%
84
betamethasone valerate lotion 0.1%
84
betamethasone valerate oint 0.1%
84
BETASERON INJ 0.3MG
122
betaxolol hcl ophth soln 0.5%
114
betaxolol hcl tab 10 mg
66
betaxolol hcl tab 20 mg
66
bethanechol chloride tab 10 mg
131
bethanechol chloride tab 25 mg
131
bethanechol chloride tab 5 mg
131
bethanechol chloride tab 50 mg
131
BETIMOL SOL 0.25%
114
BETIMOL SOL 0.5%
114
BETOPTIC-S SUS 0.25% OP
114
BEYAZ TAB
73
bicalutamide tab 50 mg
50
BICILLIN C-R INJ 1200000
120
BICILLIN C-R INJ 900/300
120
BICILLIN L-A INJ 1200000
119
BICILLIN L-A INJ 2400000
119
BICILLIN L-A INJ 600000
119
BICNU INJ 100MG
48
BILTRICIDE TAB 600MG
14
bio-d-mulsio liq 400unit
134
BIO-STATIN CAP 1000000
39
BIO-STATIN CAP 500000
39
bisoprolol & hydrochlorothiazide tab 106.25 mg
45
bisoprolol & hydrochlorothiazide tab 2.56.25 mg
45
bisoprolol & hydrochlorothiazide tab 56.25 mg
45
bisoprolol fumarate tab 10 mg
66
bisoprolol fumarate tab 5 mg
66
bleomycin sulfate for inj 15 unit
51
bleomycin sulfate for inj 30 unit
51
BLEPHAMIDE OIN S.O.P.
116
BLEPHAMIDE SUS OP
116
BLOOD GLUCOSE CALIBRATION
SOLUTION
107
BOOSTRIX INJ
127
BOSULIF TAB 100MG
52
BOSULIF TAB 500MG
52
BOTOX INJ 100UNIT
114
BOTOX INJ 200UNIT
114
bp 7% wash kit
80
bp gel gel 5%
80
139
bp wash liq 2.5%
80
bp wash liq 7%
80
BPO CLOTHS MIS 3%
80
BPO CLOTHS MIS 6%
80
BPO CLOTHS MIS 9%
80
BPO GEL 4%
80
BPO GEL 8%
80
BREO ELLIPTA INH 100-25
21
BRILINTA TAB 90MG
101
brimonidine tartrate ophth soln 0.15% 115
brimonidine tartrate ophth soln 0.2% 115
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
117
bromfenac sodium ophth soln 0.09%
(base equivalent)
117
bromocriptine mesylate cap 5 mg
56
bromocriptine mesylate tab 2.5 mg
56
brompheniramine tannate chew tab 12
mg
40
BROVANA NEB 15MCG
21
budeprion tab 100mg sr
28
budeprion tab 150mg sr
28
budeprion xl tab 150mg
28
budeprion xl tab 300mg
28
budesonide cap sr 24hr 3 mg
76
budesonide inhalation susp 0.25
mg/2ml
21
budesonide inhalation susp 0.5 mg/2ml 21
bumetanide inj 0.25 mg/ml
88
bumetanide tab 0.5 mg
89
bumetanide tab 1 mg
89
bumetanide tab 2 mg
89
BUPHENYL TAB 500MG
92
buprenorphine hcl inj 0.3 mg/ml (base
equiv)
13
buprenorphine hcl sl tab 2 mg (base
equiv)
13
buprenorphine hcl sl tab 8 mg (base
equiv)
13
buproban tab 150mg
123
bupropion hcl (smoking deterrent) tab sr
12hr 150 mg
123
bupropion hcl tab 100 mg
28
bupropion hcl tab 75 mg
28
bupropion hcl tab sr 12hr 100 mg
28
bupropion hcl tab sr 12hr 150 mg
28
bupropion hcl tab sr 12hr 200 mg
28
bupropion hcl tab sr 24hr 150 mg
28
bupropion hcl tab sr 24hr 300 mg
28
buspirone hcl tab 10 mg
17
buspirone hcl tab 15 mg
17
buspirone hcl tab 30 mg
17
buspirone hcl tab 5 mg
17
buspirone hcl tab 7.5 mg
17
BUSULFEX INJ 6MG/ML
48
butalbital-acetaminophen-caffeine cap 50325-40 mg
7
butalbital-acetaminophen-caffeine tab 50325-40 mg
7
butalbital-aspirin-caffeine cap 50-325-40
mg
7
butalbital-aspirin-caffeine tab 50-325-40
mg
7
butorphanol tartrate inj 1 mg/ml
13
butorphanol tartrate inj 2 mg/ml
13
butorphanol tartrate nasal soln 10
mg/ml
13
BUTRANS DIS 10MCG/HR
13
BUTRANS DIS 15MCG/HR
13
BUTRANS DIS 20MCG/HR
13
BUTRANS DIS 5MCG/HR
13
BYDUREON INJ
35
BYETTA INJ 10MCG
35
BYETTA INJ 5MCG
35
BYSTOLIC TAB 10MG
66
BYSTOLIC TAB 2.5MG
66
BYSTOLIC TAB 20MG
66
BYSTOLIC TAB 5MG
66
C
cabergoline tab 0.5 mg
93
CAFERGOT TAB 1-100MG
107
calcipotriene cream 0.005%
83
calcipotriene oint 0.005%
83
calcipotriene soln 0.005% (50 mcg/ml) 83
calcitonin (salmon) nasal soln 200
unit/act
90
calcitrene oin 0.005%
84
calcitriol cap 0.25 mcg
92
calcitriol cap 0.5 mcg
92
calcitriol inj 1 mcg/ml
92
calcitriol oint 3 mcg/gm
84
calcitriol oral soln 1 mcg/ml
92
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)
100
calcium acetate (phosphate binder) tab
667 mg
100
camila tab 0.35mg
76
CAMPATH INJ 30MG/ML
50
CAMPRAL TAB 333MG
121
CAMPTOSAR INJ 300/15ML
55
CANASA SUP 1000MG
99
CANCIDAS INJ 50MG
39
CANCIDAS INJ 70MG
39
candesartan cilexetil tab 16 mg
44
candesartan cilexetil tab 32 mg
44
candesartan cilexetil tab 4 mg
44
candesartan cilexetil tab 8 mg
44
candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg
45
candesartan cilexetil-hydrochlorothiazide
tab 32-12.5 mg
45
candesartan cilexetil-hydrochlorothiazide
tab 32-25 mg
45
CANTIL TAB 25MG
127
CAPASTAT SUL INJ 1GM
48
capecitabine tab 150 mg
49
capecitabine tab 500 mg
49
CAPEX SHA 0.01%
85
CAPITAL/COD SUS 120-12/5
12
CAPRELSA TAB 100MG
52
140
CAPRELSA TAB 300MG
52
captopril & hydrochlorothiazide tab 25-15
mg
45
captopril & hydrochlorothiazide tab 25-25
mg
45
captopril & hydrochlorothiazide tab 50-15
mg
46
captopril & hydrochlorothiazide tab 50-25
mg
46
captopril tab 100 mg
43
captopril tab 12.5 mg
43
captopril tab 25 mg
43
captopril tab 50 mg
43
CARAC CRE 0.5%
83
CARAFATE SUS 1GM/10ML
129
CARBAGLU TAB 200MG
92
carbamazepine cap sr 12hr 100 mg
24
carbamazepine cap sr 12hr 200 mg
24
carbamazepine cap sr 12hr 300 mg
24
carbamazepine chew tab 100 mg
24
carbamazepine susp 100 mg/5ml
25
carbamazepine tab 200 mg
25
carbamazepine tab sr 12hr 200 mg
25
carbamazepine tab sr 12hr 400 mg
25
carbidopa & levodopa orally disintegrating
tab 10-100 mg
56
carbidopa & levodopa orally disintegrating
tab 25-100 mg
56
carbidopa & levodopa orally disintegrating
tab 25-250 mg
56
carbidopa & levodopa tab 10-100 mg
56
carbidopa & levodopa tab 25-100 mg
56
carbidopa & levodopa tab 25-250 mg
56
carbidopa & levodopa tab cr 25-100 mg 56
carbidopa & levodopa tab cr 50-200 mg 56
carbidopa tab 25 mg
55
carbidopa-levodopa-entacapone tabs 12.550-200 mg
56
carbidopa-levodopa-entacapone tabs
18.75-75-200 mg
56
carbidopa-levodopa-entacapone tabs 25100-200 mg
56
carbidopa-levodopa-entacapone tabs
31.25-125-200 mg
56
carbidopa-levodopa-entacapone tabs 37.5150-200 mg
56
carbidopa-levodopa-entacapone tabs 50200-200 mg
56
carbinoxamine maleate soln 4 mg/5ml 40
carbinoxamine maleate tab 4 mg
40
carboplatin iv for inj 150 mg
48
carboplatin iv soln 150 mg/15ml
48
carboplatin iv soln 450 mg/45ml
48
carboplatin iv soln 50 mg/5ml
48
carboplatin iv soln 600 mg/60ml
48
CARDENE IV INJ 40/200ML
67
CARDENE IV SOL 20/200ML
67
CARDIZEM LA TAB 120MG
67
CARDURA XL TAB 4MG
100
CARDURA XL TAB 8MG
100
CARIMUNE NF INJ 12GM
118
CARIMUNE NF INJ 3GM
CARIMUNE NF INJ 6GM
carisoprodol tab 250 mg
carisoprodol tab 350 mg
carteolol hcl ophth soln 1%
cartia xt cap 120/24hr
cartia xt cap 180/24hr
cartia xt cap 240/24hr
cartia xt cap 300/24hr
carvedilol tab 12.5 mg
carvedilol tab 25 mg
carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
CAYSTON INH 75MG
caziant pak
CEDAX SUS 90MG/5ML
cefaclor cap 250 mg
cefaclor cap 500 mg
CEFACLOR ER TAB 500MG
cefaclor for susp 125 mg/5ml
cefaclor for susp 250 mg/5ml
cefaclor for susp 375 mg/5ml
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
CEFAZOL/DEX SOL 1GM
CEFAZOL/DEX SOL 2GM
CEFAZOLIN INJ 1GM/50ML
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 10 gm
cefazolin sodium for inj 20 gm
cefazolin sodium for inj 500 mg
cefazolin sodium for iv soln 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefditoren pivoxil tab 200 mg (base
equivalent)
cefditoren pivoxil tab 400 mg (base
equivalent)
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
CEFEPIME INJ 1GM
CEFEPIME INJ 2GM
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 10 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 500 mg
CEFOTET/DEX INJ 1-3.58%
CEFOTET/DEX INJ 2-2.08%
CEFOTETAN INJ 10G
CEFOTETAN INJ 1GM/10ML
CEFOTETAN INJ 2GM/20ML
CEFOXITIN INJ 1GM
CEFOXITIN INJ 2GM
cefoxitin sodium for inj 1 gm
cefoxitin sodium for inj 10 gm
cefoxitin sodium for inj 2 gm
cefpodoxime proxetil for susp 100
118
118
112
112
114
67
67
67
67
65
65
65
65
14
73
71
71
71
71
71
71
71
70
70
70
70
70
70
70
70
70
70
70
70
71
71
71
72
72
73
73
73
73
72
72
72
72
71
71
71
71
71
71
71
71
71
71
141
mg/5ml
72
cefpodoxime proxetil for susp 50
mg/5ml
72
cefpodoxime proxetil tab 100 mg
72
cefpodoxime proxetil tab 200 mg
72
cefprozil for susp 125 mg/5ml
71
cefprozil for susp 250 mg/5ml
71
cefprozil tab 250 mg
71
cefprozil tab 500 mg
71
ceftazidime for inj 1 gm
72
ceftazidime for inj 2 gm
72
ceftazidime for inj 500 mg
72
ceftazidime for inj 6 gm
72
CEFTAZIDIME INJ 100GM
72
CEFTAZIDIME/ SOL D5W 1GM
72
CEFTAZIDIME/ SOL D5W 2GM
72
ceftibuten cap 400 mg
72
ceftibuten for susp 180 mg/5ml
72
CEFTIN SUS 250/5ML
71
CEFTRIAXONE INJ 100GM
72
ceftriaxone sodium for inj 1 gm
72
ceftriaxone sodium for inj 10 gm
72
ceftriaxone sodium for inj 2 gm
72
ceftriaxone sodium for inj 250 mg
72
ceftriaxone sodium for inj 500 mg
72
ceftriaxone sodium for iv soln 1 gm
72
ceftriaxone sodium for iv soln 2 gm
72
CEFUROX/DEXT INJ 1.5GM
71
CEFUROX/DEXT INJ 750MG
71
cefuroxime axetil for susp 125 mg/5ml 71
cefuroxime axetil tab 250 mg
71
cefuroxime axetil tab 500 mg
71
CEFUROXIME INJ 225GM
71
CEFUROXIME INJ 7.5GM
71
CEFUROXIME INJ 75GM
71
cefuroxime sodium for inj 1.5 gm
71
cefuroxime sodium for inj 7.5 gm
71
cefuroxime sodium for inj 750 mg
71
cefuroxime sodium for iv soln 1.5 gm
71
CELEBREX CAP 100MG
5
CELEBREX CAP 200MG
5
CELEBREX CAP 400MG
5
CELEBREX CAP 50MG
5
CELLCEPT IV INJ 500MG
64
CELLCEPT SUS 200MG/ML
64
CELONTIN CAP 300MG
27
CENESTIN TAB 0.3MG
94
CENESTIN TAB 0.45MG
94
CENESTIN TAB 0.625MG
94
CENESTIN TAB 0.9MG
94
CENESTIN TAB 1.25MG
94
cephalexin cap 250 mg
70
cephalexin cap 500 mg
70
cephalexin cap 750 mg
70
cephalexin for susp 125 mg/5ml
70
cephalexin for susp 250 mg/5ml
70
cephalexin tab 250 mg
70
cephalexin tab 500 mg
70
CEREZYME INJ 200UNIT
101
CEREZYME INJ 400UNIT
101
CERVARIX INJ
132
CESAMET CAP 1MG
38
cesia pak
73
cevimeline hcl cap 30 mg
111
CHANTIX PAK 0.5& 1MG
123
CHANTIX PAK 1MG
123
CHANTIX TAB 0.5MG
123
CHANTIX TAB 1MG
123
chateal tab 0.15/30
73
CHEMET CAP 100MG
37
child vit d chw 400unit
134
chloramphenicol sodium succinate for iv
inj 1 gm
15
chlorhexidine gluconate soln 0.12%
111
chloroquine phosphate tab 250 mg
47
chloroquine phosphate tab 500 mg
47
chlorothiazide sodium for inj 500 mg
89
chlorothiazide tab 250 mg
89
chlorothiazide tab 500 mg
89
CHLORPROMAZ INJ 25MG/ML
59
chlorpromazine hcl tab 10 mg
59
chlorpromazine hcl tab 100 mg
59
chlorpromazine hcl tab 200 mg
59
chlorpromazine hcl tab 25 mg
59
chlorpromazine hcl tab 50 mg
59
chlorpropamide tab 100 mg
36
chlorpropamide tab 250 mg
36
chlorthalidone tab 100 mg
89
chlorthalidone tab 25 mg
89
chlorthalidone tab 50 mg
89
chlorzoxazone tab 500 mg
112
cholestyramine light powder 4 gm/dose 41
cholestyramine light powder packets 4
gm
41
cholestyramine powder 4 gm/dose
41
cholestyramine powder packets 4 gm
41
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv)
42
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv)
42
chorionic gonadotropin for inj 10000
unit
90
CIALIS TAB 2.5MG
70
ciclopirox gel 0.77%
82
ciclopirox olamine cream 0.77% (base
equiv)
82
ciclopirox olamine susp 0.77% (base
equiv)
82
ciclopirox shampoo 1%
82
cidofovir iv inj 75 mg/ml
62
cilostazol tab 100 mg
101
cilostazol tab 50 mg
101
CILOXAN OIN 0.3% OP
115
cimetidine hcl soln 300 mg/5ml
128
cimetidine tab 200 mg
128
cimetidine tab 300 mg
128
cimetidine tab 400 mg
128
cimetidine tab 800 mg
128
CIMZIA KIT
99
CIMZIA KIT STARTER
99
142
CIMZIA PREFL KIT 200MG/ML
99
CIPRO (10%) SUS 500MG/5
98
CIPRO (5%) SUS 250MG/5
98
CIPRO HC SUS OTIC
117
CIPRODEX SUS 0.3-0.1%
117
ciprofloxacin 200 mg/100ml in d5w
98
ciprofloxacin 400 mg/200ml in d5w
98
ciprofloxacin hcl ophth soln 0.3%
115
ciprofloxacin hcl tab 100 mg (base
equiv)
98
ciprofloxacin hcl tab 250 mg (base
equiv)
98
ciprofloxacin hcl tab 500 mg (base
equiv)
98
ciprofloxacin hcl tab 750 mg (base
equiv)
98
ciprofloxacin iv soln 200 mg/20ml (1%) 98
ciprofloxacin iv soln 400 mg/40ml (1%) 98
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)
98
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq)
98
cisplatin inj 100 mg/100ml (1 mg/ml) 48
cisplatin inj 200 mg/200ml (1 mg/ml) 48
cisplatin inj 50 mg/50ml (1 mg/ml)
48
citalopram hydrobromide oral soln 10
mg/5ml
29
citalopram hydrobromide tab 10 mg (base
equiv)
29
citalopram hydrobromide tab 20 mg (base
equiv)
29
citalopram hydrobromide tab 40 mg (base
equiv)
29
CITRANATAL CAP HARMONY
111
CITRANATAL MIS 90 DHA
112
CITRANATAL MIS B-CALM
112
CITRANATAL PAK ASSURE
112
CITRANATAL PAK DHA
112
CITRANATAL TAB RX
112
cladribine inj 1 mg/ml
49
CLAFORAN INJ 1GM
72
CLAFORAN INJ 2GM
72
claravis cap 10mg
80
claravis cap 20mg
80
claravis cap 30mg
80
claravis cap 40mg
80
CLARINEX SYP 0.5MG/ML
40
clarithromycin for susp 125 mg/5ml
105
clarithromycin for susp 250 mg/5ml
105
clarithromycin tab 250 mg
105
clarithromycin tab 500 mg
105
clarithromycin tab sr 24hr 500 mg
105
clearplex x gel 10%
80
clemastine fumarate syrup 0.67 mg/5ml
(0.5 mg/5ml base eq)
40
clemastine fumarate tab 2.68 mg
40
clenia cre 10-5%
80
CLEOCIN SUP 100MG
133
clidinium & chlordiazepoxide cap 2.5-5
mg
127
CLIMARA PRO DIS WEEKLY
93
CLINAC BPO GEL 7%
80
clindamax gel 1%
80
clindamax lot 10mg/ml
80
clindamycin hcl cap 150 mg
16
clindamycin hcl cap 300 mg
16
clindamycin hcl cap 75 mg
16
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
16
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%
80
clindamycin phosphate foam 1%
80
clindamycin phosphate gel 1%
80
clindamycin phosphate inj 300 mg/2ml 16
clindamycin phosphate inj 600 mg/4ml 16
clindamycin phosphate inj 9 gm/60ml 16
clindamycin phosphate inj 900 mg/6ml 16
clindamycin phosphate iv soln 300
mg/2ml
16
clindamycin phosphate iv soln 600
mg/4ml
16
clindamycin phosphate iv soln 900
mg/6ml
16
clindamycin phosphate lotion 1%
80
clindamycin phosphate soln 1%
80
clindamycin phosphate swab 1%
80
clindamycin phosphate vaginal cream
2%
133
clindamycin phosphate-benzoyl peroxide
gel 1-5%
80
clobetasol propionate cream 0.05%
85
clobetasol propionate foam 0.05%
85
clobetasol propionate gel 0.05%
85
clobetasol propionate lotion 0.05%
85
clobetasol propionate oint 0.05%
85
clobetasol propionate shampoo 0.05% 85
clobetasol propionate soln 0.05%
85
CLOBEX SPR 0.05%
85
clocortolone pivalate cream 0.1%
85
CLOLAR INJ 1MG/ML
49
clomipramine hcl cap 25 mg
31
clomipramine hcl cap 50 mg
31
clomipramine hcl cap 75 mg
31
clonazepam tab 0.5 mg
24
clonazepam tab 1 mg
24
clonazepam tab 2 mg
24
clonidine hcl tab 0.1 mg
44
clonidine hcl tab 0.2 mg
44
clonidine hcl tab 0.3 mg
44
clonidine hcl td patch weekly 0.1
mg/24hr
44
clonidine hcl td patch weekly 0.2
mg/24hr
44
clonidine hcl td patch weekly 0.3
mg/24hr
44
clopidogrel bisulfate tab 300 mg (base
equiv)
101
clopidogrel bisulfate tab 75 mg (base
equiv)
101
clorazepate dipotassium tab 15 mg
18
clorazepate dipotassium tab 3.75 mg
18
clorazepate dipotassium tab 7.5 mg
18
143
clotrimazole cream 1%
82
CLOTRIMAZOLE CRY
82
clotrimazole soln 1%
82
clotrimazole troche 10 mg
110
clotrimazole w/ betamethasone cream 10.05%
82
clotrimazole w/ betamethasone lotion 10.05%
82
clozapine tab 100 mg
58
clozapine tab 200 mg
58
clozapine tab 25 mg
58
clozapine tab 50 mg
58
COARTEM TAB 20-120MG
47
cobal-1000 inj 1000mcg
102
CODEINE SULF SOL 30MG/5ML
8
codeine sulfate tab 15 mg
8
codeine sulfate tab 30 mg
8
codeine sulfate tab 60 mg
8
CODEINE/GUAI LIQ 10-300MG
78
colchicine w/ probenecid tab 0.5-500
mg
100
COLCRYS TAB 0.6MG
101
colestipol hcl granule packets 5 gm
41
colestipol hcl granules 5 gm
41
colestipol hcl tab 1 gm
41
colocort ene 100mg
14
COLYTE/FLAVR SOL PACKS
104
COMBIGAN SOL 0.2/0.5%
114
COMBIVENT AER RESPIMAT
22
COMETRIQ KIT 100MG
52
COMETRIQ KIT 140MG
52
COMETRIQ KIT 60MG
52
COMPLERA TAB
60
compro sup 25mg
59
COMVAX INJ
132
CONCEPTROL GEL 4%
133
CONDYLOX GEL 0.5%
87
constulose sol 10gm/15
104
COPAXONE INJ 40MG/ML
123
COPAXONE KIT 20MG/ML
123
CORDRAN 24X3 TAP 4MCG/CM
85
CORDRAN LOT 0.05%
85
CORDRAN SP CRE 0.05%
85
COREG CR CAP 10MG
65
COREG CR CAP 20MG
65
COREG CR CAP 40MG
65
COREG CR CAP 80MG
65
cormax oin 0.05%
85
cortisone acetate tab 25 mg
76
CORTISPORIN CRE 0.5%
82
CORTISPORIN OIN 1%
82
CORTISPORIN SUS -TC OTIC
117
cortomycin sol 1% otic
117
cortomycin sus 1% otic
117
COUMADIN INJ 5 MG
23
CREON CAP 12000UNT
88
CREON CAP 24000UNT
88
CREON CAP 3000UNIT
88
CREON CAP 36000UNT
88
CREON CAP 6000UNIT
88
CRESTOR TAB 10MG
42
CRESTOR TAB 20MG
42
CRESTOR TAB 40MG
42
CRESTOR TAB 5MG
42
CRINONE GEL 4% VAG
134
CRINONE GEL 8% VAG
134
CRIXIVAN CAP 100MG
60
CRIXIVAN CAP 200MG
60
CRIXIVAN CAP 400MG
60
cromolyn sodium ophth soln 4%
117
cromolyn sodium oral conc 100 mg/5ml 99
cromolyn sodium soln nebu 20 mg/2ml 20
cryselle-28 tab 28 tabs
73
CUBICIN SOL 500MG
15
CUVPOSA SOL 1MG/5ML
127
cyanocobalamin inj 1000 mcg/ml
102
cyclafem tab 1/35
73
cyclafem tab 7/7/7
73
cyclobenzaprine hcl tab 10 mg
112
cyclobenzaprine hcl tab 5 mg
112
cyclobenzaprine hcl tab 7.5 mg
112
CYCLOPHOSPH INJ 1GM
48
CYCLOPHOSPH INJ 2GM
48
CYCLOPHOSPH INJ 500MG
48
cyclophosphamide tab 25 mg
48
cyclophosphamide tab 50 mg
48
cycloserine cap 250 mg
48
CYCLOSET TAB 0.8MG
35
cyclosporine cap 100 mg
64
cyclosporine cap 25 mg
64
cyclosporine iv soln 50 mg/ml
64
cyclosporine modified cap 100 mg
64
cyclosporine modified cap 25 mg
64
cyclosporine modified cap 50 mg
64
cyclosporine modified oral soln 100
mg/ml
64
cyproheptadine hcl syrup 2 mg/5ml
41
cyproheptadine hcl tab 4 mg
41
CYSTADANE POW
92
CYSTAGON CAP 150MG
100
CYSTAGON CAP 50MG
100
cytarabine for inj 1 gm
49
cytarabine for inj 100 mg
49
cytarabine for inj 500 mg
49
cytarabine inj 20 mg/ml
49
cytarabine inj pf 100 mg/ml
49
cytarabine inj pf 20 mg/ml
49
D
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
dactinomycin for inj 0.5 mg
DALIRESP TAB 500MCG
danazol cap 100 mg
danazol cap 200 mg
danazol cap 50 mg
dantrolene sodium cap 100 mg
dantrolene sodium cap 25 mg
dantrolene sodium cap 50 mg
53
53
51
20
13
13
13
113
113
113
144
dapsone tab 100 mg
16
dapsone tab 25 mg
15
DAPTACEL INJ
127
DARAPRIM TAB 25MG
47
dasetta tab 1/35
73
dasetta tab 7/7/7
73
daunorubicin hcl for inj 20 mg
51
daunorubicin hcl inj 5 mg/ml (base
equiv)
51
DAUNOXOME INJ 2MG/ML
51
DAYTRANA DIS 10MG/9HR
2
DAYTRANA DIS 15MG/9HR
2
DAYTRANA DIS 20MG/9HR
2
DAYTRANA DIS 30MG/9HR
2
DECAVAC INJ 5-2LF
127
decitabine for inj 50 mg
49
DELOS LIQ 3.5%
80
DELOS LOT 3.5%
80
demeclocycline hcl tab 150 mg
124
demeclocycline hcl tab 300 mg
124
DENAVIR CRE 1%
84
depade tab 50mg
37
DEPEN TITRA TAB 250MG
64
DEPO-ESTRADI INJ 5MG/ML
94
DEPO-MEDROL INJ 20MG/ML
76
DEPO-PROVERA INJ 400/ML
50
DEPO-SQ PROV INJ 104
76
DEPOCYT INJ 50MG/5ML
49
desipramine hcl tab 10 mg
31
desipramine hcl tab 100 mg
31
desipramine hcl tab 150 mg
31
desipramine hcl tab 25 mg
31
desipramine hcl tab 50 mg
31
desipramine hcl tab 75 mg
31
desloratadine tab 5 mg
40
desloratadine tab orally disintegrating 2.5
mg
40
desloratadine tab orally disintegrating 5
mg
40
desmopressin acetate inj 4 mcg/ml
92
desmopressin acetate nasal soln 0.01%
(refrigerated)
92
desmopressin acetate nasal spray soln
0.01%
92
desmopressin acetate nasal spray soln
0.01% (refrigerated)
92
desmopressin acetate tab 0.1 mg
92
desmopressin acetate tab 0.2 mg
92
DESONATE GEL 0.05%
85
desonide cream 0.05%
85
desonide lotion 0.05%
85
desonide oint 0.05%
85
DESOWEN OINT KIT 0.05%
85
desoximetasone cream 0.05%
85
desoximetasone cream 0.25%
85
desoximetasone gel 0.05%
85
desoximetasone oint 0.05%
85
desoximetasone oint 0.25%
85
DEXAMETHASON CON 1MG/ML
76
dexamethasone elixir 0.5 mg/5ml
76
dexamethasone sod phosphate
preservative free inj 10 mg/ml
76
dexamethasone sodium phosphate inj 100
mg/10ml
76
dexamethasone sodium phosphate inj 20
mg/5ml
76
dexamethasone sodium phosphate ophth
soln 0.1%
116
dexamethasone soln 0.5 mg/5ml
76
dexamethasone tab 0.5 mg
76
dexamethasone tab 0.75 mg
76
dexamethasone tab 1 mg
76
dexamethasone tab 1.5 mg
76
dexamethasone tab 2 mg
76
dexamethasone tab 4 mg
76
dexamethasone tab 6 mg
76
dexchlorpheniramine maleate syrup 2
mg/5ml
40
DEXILANT CAP 30MG DR
129
DEXILANT CAP 60MG DR
129
dexmethylphenidate hcl cap sr 24 hr 15
mg
2
dexmethylphenidate hcl cap sr 24 hr 30
mg
2
dexmethylphenidate hcl cap sr 24 hr 40
mg
3
dexmethylphenidate hcl tab 10 mg
3
dexmethylphenidate hcl tab 2.5 mg
3
dexmethylphenidate hcl tab 5 mg
3
DEXPAK PAK 10 DAY
76
DEXPAK PAK 13 DAY
76
DEXPAK PAK 6 DAY
76
dexrazoxane for inj 250 mg
54
dexrazoxane for inj 500 mg
54
dextroamphetamine sulfate cap sr 24hr 10
mg
1
dextroamphetamine sulfate cap sr 24hr 15
mg
1
dextroamphetamine sulfate cap sr 24hr 5
mg
1
dextroamphetamine sulfate tab 10 mg
1
dextroamphetamine sulfate tab 5 mg
1
dextrose inj 32 mg/50ml
and ondansetron hcl
38
DIAZEPAM CON 5MG/ML
18
diazepam soln 1 mg/ml
18
diazepam tab 10 mg
19
diazepam tab 2 mg
18
diazepam tab 5 mg
19
DIBENZYLINE CAP 10MG
44
diclofenac potassium tab 50 mg
5
diclofenac sodium ophth soln 0.1%
117
diclofenac sodium tab delayed release 25
mg
5
diclofenac sodium tab delayed release 50
mg
5
diclofenac sodium tab delayed release 75
mg
5
diclofenac sodium tab sr 24hr 100 mg
5
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg
5
145
diclofenac w/ misoprostol tab delayed
release 75-0.2 mg
5
dicloxacillin sodium cap 250 mg
121
dicloxacillin sodium cap 500 mg
121
dicyclomine hcl cap 10 mg
127
dicyclomine hcl oral soln 10 mg/5ml
127
dicyclomine hcl tab 20 mg
127
didanosine delayed release capsule 125
mg
60
didanosine delayed release capsule 200
mg
60
didanosine delayed release capsule 250
mg
60
didanosine delayed release capsule 400
mg
60
DIFFERIN GEL 0.3%
80
DIFFERIN LOT 0.1%
80
DIFICID TAB 200MG
106
diflorasone diacetate cream 0.05%
85
diflorasone diacetate oint 0.05%
85
diflunisal tab 500 mg
7
digox tab 0.125mg
69
digox tab 0.25mg
69
digoxin inj 0.25 mg/ml
69
digoxin oral soln 0.05 mg/ml
69
digoxin tab 125 mcg (0.125 mg)
69
digoxin tab 250 mcg (0.25 mg)
69
dihydroergotamine mesylate inj 1
mg/ml
107
dihydroergotamine mesylate nasal spray 4
mg/ml
107
DILANTIN CAP 30MG
27
DILATRATE SR CAP 40MG
16
DILAUDID-HP INJ 250MG
8
dilt-cd cap 120mg
67
dilt-cd cap 180mg
67
dilt-cd cap 240mg
67
dilt-cd cap 300mg
67
diltiazem hcl cap sr 12hr 120 mg
67
diltiazem hcl cap sr 12hr 60 mg
67
diltiazem hcl cap sr 12hr 90 mg
67
diltiazem hcl cap sr 24hr 120 mg
67
diltiazem hcl cap sr 24hr 180 mg
67
diltiazem hcl cap sr 24hr 240 mg
67
diltiazem hcl coated beads cap sr 24hr 120
mg
67
diltiazem hcl coated beads cap sr 24hr 180
mg
67
diltiazem hcl coated beads cap sr 24hr 240
mg
67
diltiazem hcl coated beads cap sr 24hr 300
mg
67
diltiazem hcl coated beads cap sr 24hr 360
mg
67
diltiazem hcl extended release beads cap
sr 24hr 120 mg
68
diltiazem hcl extended release beads cap
sr 24hr 180 mg
68
diltiazem hcl extended release beads cap
sr 24hr 240 mg
68
diltiazem hcl extended release beads cap
sr 24hr 300 mg
68
diltiazem hcl extended release beads cap
sr 24hr 360 mg
68
diltiazem hcl extended release beads cap
sr 24hr 420 mg
68
diltiazem hcl iv soln 125 mg/25ml (5
mg/ml)
68
diltiazem hcl iv soln 25 mg/5ml (5
mg/ml)
68
diltiazem hcl iv soln 50 mg/10ml (5
mg/ml)
68
diltiazem hcl tab 120 mg
68
diltiazem hcl tab 30 mg
68
diltiazem hcl tab 60 mg
68
diltiazem hcl tab 90 mg
68
DILTIAZEM INJ 100MG
68
diltzac cap 120mg/24
68
diltzac cap 180mg/24
68
diltzac cap 240mg/24
68
diltzac cap 300mg/24
68
diltzac cap 360mg/24
68
dimenhydrinate tab 50 mg
38
DIOVAN TAB 160MG
44
DIOVAN TAB 320MG
44
DIOVAN TAB 40MG
44
DIOVAN TAB 80MG
44
DIP/TET PED INJ 25-5LFU
127
DIP/TET PED INJ 6.7-5LF
127
DIPENTUM CAP 250MG
99
diphenhydramine hcl cap 25 mg
40
diphenhydramine hcl cap 50 mg
40
diphenhydramine hcl elixir 12.5 mg/5ml 40
diphenhydramine hcl inj 50 mg/ml
40
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
37
diphenoxylate w/ atropine tab 2.5-0.025
mg
37
dipyridamole tab 25 mg
101
dipyridamole tab 50 mg
101
dipyridamole tab 75 mg
101
disopyramide phosphate cap 100 mg
19
disopyramide phosphate cap 150 mg
19
disulfiram tab 250 mg
121
disulfiram tab 500 mg
121
DIURIL SUS 250/5ML
89
divalproex sodium cap sprinkle 125 mg 27
divalproex sodium tab delayed release 125
mg
27
divalproex sodium tab delayed release 250
mg
27
divalproex sodium tab delayed release 500
mg
27
divalproex sodium tab sr 24 hr 250 mg 27
divalproex sodium tab sr 24 hr 500 mg 27
DIVIGEL GEL 0.25MG
94
DIVIGEL GEL 0.5MG
94
DIVIGEL GEL 1MG/GM
94
DOCEFREZ INJ 20MG
54
DOCEFREZ INJ 80MG
54
docetaxel for inj conc 20 mg/ml
54
docetaxel for inj conc 80 mg/4ml (20
146
mg/ml)
54
DOCETAXEL INJ 160/16ML
54
DOCETAXEL INJ 20/0.5ML
54
DOCETAXEL INJ 20MG/2ML
54
DOCETAXEL INJ 80MG/2ML
54
DOCETAXEL INJ 80MG/8ML
54
donepezil hydrochloride orally
disintegrating tab 10 mg
122
donepezil hydrochloride orally
disintegrating tab 5 mg
121
donepezil hydrochloride tab 10 mg
122
donepezil hydrochloride tab 23 mg
122
donepezil hydrochloride tab 5 mg
122
DORIBAX INJ 250MG
15
DORIBAX INJ 500MG
15
dorzolamide hcl ophth soln 2%
117
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml
114
doxazosin mesylate tab 1 mg
44
doxazosin mesylate tab 2 mg
44
doxazosin mesylate tab 4 mg
44
doxazosin mesylate tab 8 mg
44
doxepin hcl cap 10 mg
31
doxepin hcl cap 100 mg
32
doxepin hcl cap 150 mg
32
doxepin hcl cap 25 mg
31
doxepin hcl cap 50 mg
31
doxepin hcl cap 75 mg
32
doxepin hcl conc 10 mg/ml
32
doxercalciferol cap 0.5 mcg
92
doxercalciferol cap 1 mcg
92
doxercalciferol cap 2.5 mcg
92
doxercalciferol inj 4 mcg/2ml (2
mcg/ml)
92
doxorubicin hcl for inj 10 mg
51
doxorubicin hcl for inj 50 mg
51
doxorubicin hcl inj 2 mg/ml
51
doxy 100 inj 100mg
124
DOXYCYCL HYC CAP 100MG
124
doxycycline hyclate cap 100 mg
124
doxycycline hyclate cap 50 mg
124
doxycycline hyclate for inj 100 mg
125
doxycycline hyclate tab 100 mg
125
doxycycline hyclate tab 20 mg
125
doxycycline hyclate tab delayed release
100 mg
125
doxycycline hyclate tab delayed release
150 mg
125
doxycycline hyclate tab delayed release 75
mg
125
doxycycline monohydrate cap 100 mg 125
doxycycline monohydrate cap 150 mg 125
doxycycline monohydrate cap 50 mg 125
doxycycline monohydrate cap 75 mg 125
doxycycline monohydrate for susp 25
mg/5ml
125
doxycycline monohydrate tab 150 mg 125
doxycycline monohydrate tab 50 mg 125
doxycycline monohydrate tab 75 mg 125
dronabinol cap 10 mg
38
dronabinol cap 2.5 mg
38
dronabinol cap 5 mg
38
drospirenone-ethinyl estradiol tab 3-0.03
mg
73
DROXIA CAP 200MG
102
DROXIA CAP 300MG
102
DROXIA CAP 400MG
102
DULERA AER 100-5MCG
22
DULERA AER 200-5MCG
22
duloxetine hcl cap 20 mg
30
duloxetine hcl cap 30 mg
30
duloxetine hcl cap 60 mg
30
DUREZOL EMU 0.05%
116
DYRENIUM CAP 100MG
89
DYRENIUM CAP 50MG
89
E
e.e.s. 400 tab 400mg
105
E.E.S. GRAN SUS 200/5ML
105
e.s.p. sus 200-600
15
econazole nitrate cream 1%
82
ed-spaz tab 0.125mg
127
EDARBI TAB 40MG
44
EDARBI TAB 80MG
44
EDECRIN TAB 25MG
89
EDURANT TAB 25MG
60
EFFIENT TAB 10MG
101
EFFIENT TAB 5MG
101
ELAPRASE INJ 6MG/3ML
92
ELELYSO INJ 200UNIT
101
ELESTRIN GEL 0.06%
94
ELIDEL CRE 1%
87
ELIGARD INJ 22.5MG
50
ELIGARD INJ 30MG
50
ELIGARD INJ 45MG
50
ELIGARD INJ 7.5MG
50
elinest tab
73
ELIQUIS TAB 2.5MG
23
ELIQUIS TAB 5MG
23
ELIXOPHYLLIN ELX 80/15ML
22
ELLA TAB 30MG
75
ELMIRON CAP 100MG
100
ELOXATIN INJ 200MG
48
ELSPAR INJ 10000UNT
53
EMADINE SOL 0.05% OP
117
EMBEDA CAP 30-1.2MG
8
EMCYT CAP 140MG
50
EMEND CAP 125MG
39
EMEND CAP 40MG
39
EMEND CAP 80MG
39
EMEND PAK 80 & 125
39
emoquette tab
73
EMSAM DIS 12MG/24H
28
EMSAM DIS 6MG/24HR
28
EMSAM DIS 9MG/24HR
28
EMTRIVA CAP 200MG
61
EMTRIVA SOL 10MG/ML
61
ENABLEX TAB 15MG
131
ENABLEX TAB 7.5MG
131
enalapril maleate & hydrochlorothiazide
147
tab 10-25 mg
46
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg
46
enalapril maleate tab 10 mg
43
enalapril maleate tab 2.5 mg
43
enalapril maleate tab 20 mg
43
enalapril maleate tab 5 mg
43
ENBREL INJ 25/0.5ML
7
ENBREL INJ 25MG
7
ENBREL INJ 50MG/ML
7
ENCARE SUP 100MG
133
endocet tab 10-325mg
12
endocet tab 5-325mg
12
endocet tab 7.5-325
12
ENGERIX-B INJ 10/0.5ML
132
ENGERIX-B INJ 20MCG/ML
132
ENJUVIA TAB 0.3MG
94
ENJUVIA TAB 0.45MG
95
ENJUVIA TAB 0.625MG
95
ENJUVIA TAB 0.9MG
94
ENJUVIA TAB 1.25MG
95
enoxaparin sodium inj 100 mg/ml
23
enoxaparin sodium inj 120 mg/0.8ml
24
enoxaparin sodium inj 150 mg/ml
24
enoxaparin sodium inj 30 mg/0.3ml
23
enoxaparin sodium inj 300 mg/3ml
24
enoxaparin sodium inj 40 mg/0.4ml
23
enoxaparin sodium inj 60 mg/0.6ml
23
enoxaparin sodium inj 80 mg/0.8ml
23
enpresse-28 tab
73
entacapone tab 200 mg
55
enulose sol 10gm/15
99
EPIDUO GEL 0.1-2.5%
80
epiflur chw 0.25mg f
108
epiflur chw 0.5mg f
108
epiflur chw 1mg f
108
epinastine hcl ophth soln 0.05%
117
epinephrine hcl inj 1 mg/ml
22
epinephrine hcl soln prefilled syringe 0.1
mg/ml
22
epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)
134
epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)
134
EPIPEN 2-PAK INJ 0.3MG
134
EPIPEN INJ 0.3MG
134
EPIPEN-JR INJ 0.15MG
134
EPIPEN-JR INJ 2-PAK
134
epirubicin hcl inj 10 mg/5ml (2 mg/ml) 51
epirubicin hcl inj 150 mg/75ml (2
mg/ml)
51
epirubicin hcl inj 200 mg/100ml (2
mg/ml)
51
epirubicin hcl inj 50 mg/25ml (2 mg/ml) 51
EPIRUBICIN INJ 200MG
51
EPIRUBICIN INJ 50MG
51
epitol tab 200mg
25
EPIVIR HBV SOL 5MG/ML
61
EPIVIR SOL 10MG/ML
61
eplerenone tab 25 mg
47
eplerenone tab 50 mg
47
epoprostenol sodium for inj 0.5 mg
70
epoprostenol sodium for inj 1.5 mg
70
eprosartan mesylate tab 600 mg
44
EPZICOM TAB 600-300
61
ERAXIS INJ 100MG
39
ERAXIS INJ 50MG
39
ERBITUX INJ 100MG
50
ERBITUX INJ 200MG
50
ergocalciferol cap 50000 unit
134
ergoloid mesylates tab 1 mg
123
ERGOMAR SUB 2MG
107
ergotamine w/ caffeine tab 1-100 mg 107
ERIVEDGE CAP 150MG
50
errin tab 0.35mg
76
ERTACZO CRE 2%
83
ery pad 2%
80
ERY-TAB TAB 250MG EC
105
ERY-TAB TAB 333MG EC
105
ERY-TAB TAB 500MG EC
105
ERYPED SUS 200/5ML
105
ERYPED SUS 400/5ML
106
ERYTHROCIN INJ 1000MG
106
ERYTHROCIN INJ 500MG
106
erythrocin tab 250mg
106
erythromycin ethylsuccinate tab 400
mg
106
erythromycin gel 2%
80
erythromycin ophth oint 5 mg/gm
115
erythromycin pads 2%
80
erythromycin soln 2%
80
erythromycin tab 250 mg
106
erythromycin tab 500 mg
106
erythromycin w/ delayed release particles
cap 250 mg
106
erythromycin-sulfisoxazole for susp 200600 mg/5ml
15
escitalopram oxalate soln 5 mg/5ml (base
equiv)
29
escitalopram oxalate tab 10 mg (base
equiv)
29
escitalopram oxalate tab 20 mg (base
equiv)
29
escitalopram oxalate tab 5 mg (base
equiv)
29
esomeprazole sodium for intravenous soln
20 mg (base equiv)
129
esomeprazole sodium for intravenous soln
40 mg (base equiv)
129
ESTRACE VAG CRE 0.1MG/GM
133
estradiol & norethindrone acetate tab 0.50.1 mg
93
estradiol & norethindrone acetate tab 10.5 mg
93
estradiol tab 0.5 mg
95
estradiol tab 1 mg
95
estradiol tab 2 mg
95
estradiol td patch weekly 0.025
mg/24hr
95
estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)
96
148
estradiol td patch weekly 0.05 mg/24hr 95
estradiol td patch weekly 0.06 mg/24hr 95
estradiol td patch weekly 0.075
mg/24hr
96
estradiol td patch weekly 0.1 mg/24hr 95
estradiol valerate im in oil 10 mg/ml
96
estradiol valerate im in oil 20 mg/ml
96
estradiol valerate im in oil 40 mg/ml
96
ESTRING MIS 2MG
133
ESTROGEL GEL
96
estropipate tab 0.75 mg
96
estropipate tab 1.5 mg
96
estropipate tab 3 mg
96
ethambutol hcl tab 100 mg
48
ethambutol hcl tab 400 mg
48
ethosuximide cap 250 mg
27
ethosuximide soln 250 mg/5ml
27
etidronate disodium tab 200 mg
90
etidronate disodium tab 400 mg
90
etodolac cap 200 mg
5
etodolac cap 300 mg
5
etodolac tab 400 mg
5
etodolac tab 500 mg
5
etodolac tab sr 24hr 400 mg
5
etodolac tab sr 24hr 500 mg
5
etodolac tab sr 24hr 600 mg
5
ETOPOPHOS INJ 100MG
54
etoposide cap 50 mg
54
etoposide inj 100mg/5ml (20 mg/ml)
54
EURAX CRE 10%
87
EURAX LOT 10%
87
EVAMIST SPR 1.53MG
96
EVISTA TAB 60MG
91
EXALGO TAB 12MG
8
EXALGO TAB 16MG
8
EXALGO TAB 32MG
8
EXALGO TAB 8MG
8
EXELDERM CRE 1%
83
EXELDERM SOL 1%
83
EXELON DIS 13.3/24
122
EXELON DIS 4.6MG/24
122
EXELON DIS 9.5MG/24
122
EXELON SOL 2MG/ML
122
exemestane tab 25 mg
50
EXJADE TAB 125MG
37
EXJADE TAB 250MG
37
EXJADE TAB 500MG
37
EXTAVIA INJ 0.3MG
123
EZ FLU SHOT KIT 13-14
132
EZ FLU SHOT KIT PF 13-14
132
EZ USE FLU KIT 2012-13
132
F
FABRAZYME INJ 35MG
FABRAZYME INJ 5MG
FACTIVE TAB 320MG
falmina tab
famciclovir tab 125 mg
famciclovir tab 250 mg
92
92
98
73
63
63
famciclovir tab 500 mg
famotidine for susp 40 mg/5ml
famotidine in nacl 0.9% iv soln 20
mg/50ml
famotidine inj 40 mg/4ml
famotidine tab 20 mg
famotidine tab 40 mg
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FARESTON TAB 60MG
FASLODEX INJ 250MG
FC2 FEMALE MIS CONDOM
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
felodipine tab sr 24hr 10 mg
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
FEMCAP MIS 22MM
FEMCAP MIS 26MM
FEMCAP MIS 30MM
FEMHRT TAB 0.5-2.5
FEMRING MIS 0.05/24H
FEMRING MIS 0.1MG/24
fenofibrate micronized cap 130 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate micronized cap 43 mg
fenofibrate micronized cap 67 mg
fenofibrate tab 145 mg
fenofibrate tab 160 mg
fenofibrate tab 48 mg
fenofibrate tab 54 mg
fenofibric acid tab 105 mg
fenofibric acid tab 35 mg
fenoprofen calcium tab 600 mg
fentanyl citrate lollipop 1200 mcg
fentanyl citrate lollipop 1600 mcg
fentanyl citrate lollipop 200 mcg
fentanyl citrate lollipop 400 mcg
fentanyl citrate lollipop 600 mcg
fentanyl citrate lollipop 800 mcg
fentanyl td patch 72hr 100 mcg/hr
fentanyl td patch 72hr 12 mcg/hr
fentanyl td patch 72hr 25 mcg/hr
fentanyl td patch 72hr 50 mcg/hr
fentanyl td patch 72hr 75 mcg/hr
FENTORA TAB 100MCG
FENTORA TAB 200MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
FER-IN-SOL DRO 15MG/ML
FERRIPROX TAB 500MG
63
128
128
128
128
128
57
57
57
57
57
57
57
57
50
50
106
26
26
26
68
68
68
106
106
106
93
133
133
42
42
42
42
42
42
42
42
42
42
42
5
8
8
8
8
8
8
8
8
8
8
8
8
9
9
9
9
103
37
149
FERROUS SUL LIQ 220/5ML
103
FERROUS SULF DRO
103
FERROUS SULF SYP 300/5ML
103
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe)
103
ferrous sulfate soln 75 mg/0.6ml (15
mg/0.6ml elemental fe)
103
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
103
FINACEA GEL 15%
87
finasteride tab 5 mg
100
FIRAZYR INJ 30MG/3ML
101
FIRMAGON INJ 120MG
50
FIRMAGON INJ 80MG
50
FLAGYL ER TAB 750MG
14
FLAREX SUS 0.1% OP
116
flavoxate hcl tab 100 mg
131
FLEBOGAMMA INJ 10%
118
FLEBOGAMMA INJ 5%
118
FLEBOGAMMA INJ DIF 5%
118
flecainide acetate tab 100 mg
19
flecainide acetate tab 150 mg
19
flecainide acetate tab 50 mg
19
FLOVENT DISK AER 100MCG
21
FLOVENT DISK AER 250MCG
21
FLOVENT DISK AER 50MCG
21
FLOVENT HFA AER 110MCG
21
FLOVENT HFA AER 220MCG
21
FLOVENT HFA AER 44MCG
21
floxuridine for inj 0.5 gm
49
FLUARIX INJ PF 11-12
132
FLUARIX INJ PF 12-13
132
FLUARIX PF INJ 2013-14
132
FLUBLOK SOL 2013-14
132
FLUCELVAX INJ 2012-13
132
FLUCELVAX INJ 2013-14
132
fluconazole for susp 10 mg/ml
39
fluconazole for susp 40 mg/ml
39
fluconazole in dextrose inj 200
mg/100ml
39
fluconazole in dextrose inj 400
mg/200ml
39
fluconazole in nacl 0.9% inj 200
mg/100ml
39
fluconazole in nacl 0.9% inj 400
mg/200ml
39
fluconazole tab 100 mg
39
fluconazole tab 150 mg
39
fluconazole tab 200 mg
39
fluconazole tab 50 mg
39
FLUCONAZOLE/ INJ NACL 100
39
fludarabine phosphate for inj 50 mg
49
fludarabine phosphate inj 25 mg/ml
49
fludrocortisone acetate tab 0.1 mg
78
FLULAVAL INJ 2011-12
132
FLULAVAL INJ 2012-13
132
FLULAVAL QUA INJ 2013-14
132
FLUMIST NASA LIQ 2011-12
132
FLUMIST NASA LIQ 2012-13
132
FLUMIST QUAD SUS 2013-14
132
flunisolide nasal soln 25 mcg/act
(0.025%)
113
flunisolide nasal soln 29 mcg/act
(0.025%)
113
fluocin acet oil body
85
fluocinolone acetonide (otic) oil 0.01% 118
fluocinolone acetonide cream 0.01%
85
fluocinolone acetonide cream 0.025% 85
fluocinolone acetonide oint 0.025%
85
fluocinolone acetonide soln 0.01%
85
fluocinonide cream 0.05%
85
fluocinonide cream 0.1%
85
fluocinonide gel 0.05%
85
fluocinonide oint 0.05%
85
fluocinonide soln 0.05%
85
fluor-a-day dro 0.125mg
108
fluor-op sus 0.1% op
116
FLUORABON DRO
109
fluoritab chw 0.5mg f
109
fluoritab chw 2.2mg
109
fluoritab dro 0.125mg
109
fluorometholone ophth susp 0.1%
116
FLUOROPLEX CRE 1%
83
fluorouracil cream 5%
83
fluorouracil inj 1 gm/20ml (50 mg/ml) 49
fluorouracil inj 2.5 gm/50ml (50 mg/ml) 49
fluorouracil inj 5 gm/100ml (50 mg/ml) 49
fluorouracil inj 500 mg/10ml (50
mg/ml)
49
fluorouracil soln 2%
83
fluorouracil soln 5%
83
fluoxetine hcl cap 10 mg
29
fluoxetine hcl cap 20 mg
29
fluoxetine hcl cap 40 mg
29
fluoxetine hcl cap delayed release 90
mg
29
fluoxetine hcl solution 20 mg/5ml
29
fluoxetine hcl tab 10 mg
29
fluoxetine hcl tab 20 mg
29
FLUOXETINE TAB 60MG
29
fluphenazine decanoate inj 25 mg/ml
59
fluphenazine hcl elixir 2.5 mg/5ml
59
fluphenazine hcl inj 2.5 mg/ml
59
fluphenazine hcl oral conc 5 mg/ml
59
fluphenazine hcl tab 1 mg
59
fluphenazine hcl tab 10 mg
59
fluphenazine hcl tab 2.5 mg
59
fluphenazine hcl tab 5 mg
59
flura-drops dro 0.125mg
109
flura-drops dro 0.25mg f
109
flurbiprofen sodium ophth soln 0.03% 117
flurbiprofen tab 100 mg
5
flurbiprofen tab 50 mg
5
flutamide cap 125 mg
50
fluticasone propionate cream 0.05%
85
fluticasone propionate lotion 0.05%
85
fluticasone propionate nasal susp 50
mcg/act
113
fluticasone propionate oint 0.005%
85
fluvastatin sodium cap 20 mg
42
150
fluvastatin sodium cap 40 mg
42
FLUVIRIN INJ 2012-13
132
FLUVIRIN INJ 2013-14
132
FLUVIRIN INJ PF 11-12
132
FLUVIRIN INJ PF 12-13
132
fluvoxamine maleate cap sr 24hr 100
mg
29
fluvoxamine maleate cap sr 24hr 150
mg
29
fluvoxamine maleate tab 100 mg
29
fluvoxamine maleate tab 25 mg
29
fluvoxamine maleate tab 50 mg
29
FLUZONE HD INJ PF 11-12
132
FLUZONE HD INJ PF 12-13
132
FLUZONE HD INJ PF 13-14
132
FLUZONE INJ INTRADRM
132
FLUZONE INJ PF 11-12
132
FLUZONE INJ PF 12-13
132
FLUZONE PED/ INJ PF 11-12
132
FLUZONE PED/ INJ PF 12-13
132
FLUZONE QUAD INJ 13-14
132
FLUZONE SPLT INJ 2013-14
132
FML FORTE SUS 0.25% OP
116
FML OIN 0.1% OP
116
FOCALIN XR CAP 10MG
3
FOCALIN XR CAP 20MG
3
FOCALIN XR CAP 25MG
3
FOCALIN XR CAP 35MG
3
FOCALIN XR CAP 5MG
3
folic acid tab 1 mg
102
folic acid tab 400 mcg
102
folic acid tab 800 mcg
102
folic acid-pyridoxine-cyanocobalamin tab
2.5-25-2 mg
88
fondaparinux sodium inj 10 mg/0.8ml 24
fondaparinux sodium inj 2.5 mg/0.5ml 24
fondaparinux sodium inj 5 mg/0.4ml
24
fondaparinux sodium inj 7.5 mg/0.6ml 24
FORADIL CAP AEROLIZE
22
FORTAZ INJ 1GM
72
FORTAZ INJ 2GM
72
FORTEO SOL 600/2.4
90
FOSAMAX + D TAB 70-2800
90
FOSAMAX + D TAB 70-5600
90
FOSAMAX SOL
90
foscarnet sodium inj 24 mg/ml
62
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg
46
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg
46
fosinopril sodium tab 10 mg
43
fosinopril sodium tab 20 mg
43
fosinopril sodium tab 40 mg
43
fosphenytoin sodium inj 100 mg/2ml
(phenytoin equiv)
27
fosphenytoin sodium inj 500 mg/10ml
(phenytoin equiv)
27
FOSRENOL CHW 1000MG
100
FOSRENOL CHW 500MG
100
FOSRENOL CHW 750MG
100
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2
FRAGMIN INJ 25000/ML
FRAGMIN INJ 5000/0.2
FRAGMIN INJ 7500/0.3
FROVA TAB 2.5MG
furosemide inj 10 mg/ml
furosemide oral soln 10 mg/ml
FUROSEMIDE SOL 8MG/ML
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
FUZEON INJ 90MG
FUZEON KIT
24
24
24
24
24
24
24
24
107
89
89
89
89
89
89
61
61
G
gabapentin cap 100 mg
25
gabapentin cap 300 mg
25
gabapentin cap 400 mg
25
gabapentin oral soln 250 mg/5ml
25
gabapentin tab 600 mg
25
gabapentin tab 800 mg
25
GABITRIL TAB 12MG
27
GABITRIL TAB 16MG
27
galantamine hydrobromide cap sr 24hr 16
mg
122
galantamine hydrobromide cap sr 24hr 24
mg
122
galantamine hydrobromide cap sr 24hr 8
mg
122
galantamine hydrobromide oral soln 4
mg/ml
122
galantamine hydrobromide tab 12 mg 122
galantamine hydrobromide tab 4 mg 122
galantamine hydrobromide tab 8 mg 122
GAMASTAN S/D INJ
118
GAMMAGARD INJ 10GM/100
118
GAMMAGARD INJ 2.5GM/25
118
GAMMAGARD INJ 20GM/200
118
GAMMAGARD INJ 30GM/300
118
GAMMAGARD INJ 5GM/50ML
118
GAMMAGARD SD INJ 10GM HU
118
GAMMAGARD SD INJ 2.5GM HU
118
GAMMAGARD SD INJ 5GM HU
118
GAMMAKED INJ 10GM/100
118
GAMMAKED INJ 1GM/10ML
118
GAMMAKED INJ 2.5GM/25
118
GAMMAKED INJ 20GM/200
118
GAMMAKED INJ 5GM/50ML
118
GAMMAPLEX INJ 10GM
118
GAMMAPLEX INJ 2.5GM
118
GAMMAPLEX INJ 5GM
118
GAMUNEX INJ 10%
118
GAMUNEX-C INJ 10GM/100
118
GAMUNEX-C INJ 2.5GM/25
118
GAMUNEX-C INJ 20GM/200
118
GAMUNEX-C INJ 5GM/50ML
118
151
ganciclovir cap 250 mg
ganciclovir cap 500 mg
garamycin oin 0.3% op
GARDASIL INJ
gatifloxacin ophth soln 0.5%
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
GAZYVA INJ 25MG/ML
GELNIQUE GEL 10%
GELNIQUE GEL 3%
gemcitabine hcl for inj 1 gm
gemcitabine hcl for inj 2 gm
gemcitabine hcl for inj 200 mg
gemfibrozil tab 600 mg
GENERESS FE CHW
generlac sol 10gm/15
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
GENOTROPIN INJ 0.2MG
GENOTROPIN INJ 0.4MG
GENOTROPIN INJ 0.6MG
GENOTROPIN INJ 0.8MG
GENOTROPIN INJ 1.2MG
GENOTROPIN INJ 1.4MG
GENOTROPIN INJ 1.6MG
GENOTROPIN INJ 1.8MG
GENOTROPIN INJ 12MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
gentak oin 0.3% op
GENTAM/NACL INJ 0.9MG/ML
GENTAM/NACL INJ 1.4MG/ML
gentamicin in saline inj 0.8 mg/ml
gentamicin in saline inj 1 mg/ml
gentamicin in saline inj 1.2 mg/ml
gentamicin in saline inj 1.6 mg/ml
gentamicin in saline inj 2 mg/ml
gentamicin sulfate cream 0.1%
gentamicin sulfate inj 10 mg/ml
gentamicin sulfate inj 40 mg/ml
gentamicin sulfate iv soln 10 mg/ml
gentamicin sulfate oint 0.1%
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
gentasol sol 0.3% op
GEODON INJ 20MG
gianvi tab 3-0.02mg
gildess fe tab 1.5/30
gildess fe tab 1/20
gildess tab 1.5/30
gildess tab 1/20
GILENYA CAP 0.5MG
GLASSIA INJ
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
GLIADEL WAF 7.7MG
glimepiride tab 1 mg
62
62
115
133
115
104
104
104
50
131
131
50
50
50
42
73
99
64
64
64
91
91
91
91
91
91
91
91
91
91
91
91
115
4
4
4
4
4
4
4
82
4
4
4
82
115
115
115
57
73
73
73
73
73
123
124
52
52
48
36
glimepiride tab 2 mg
36
glimepiride tab 4 mg
36
glipizide tab 10 mg
36
glipizide tab 5 mg
36
glipizide tab sr 24hr 10 mg
36
glipizide tab sr 24hr 2.5 mg
36
glipizide tab sr 24hr 5 mg
36
glipizide-metformin hcl tab 2.5-250 mg 33
glipizide-metformin hcl tab 2.5-500 mg 33
glipizide-metformin hcl tab 5-500 mg
34
GLUCAGEN INJ HYPOKIT
34
GLUCAGON KIT 1MG
34
glyburide micronized tab 1.5 mg
36
glyburide micronized tab 3 mg
36
glyburide micronized tab 6 mg
36
glyburide tab 1.25 mg
36
glyburide tab 2.5 mg
36
glyburide tab 5 mg
36
glyburide-metformin tab 1.25-250 mg 34
glyburide-metformin tab 2.5-500 mg
34
glyburide-metformin tab 5-500 mg
34
glycopyrrolate inj 0.2 mg/ml
127
glycopyrrolate inj 0.4 mg/2ml (0.2
mg/ml)
128
glycopyrrolate inj 1 mg/5ml (0.2
mg/ml)
128
glycopyrrolate inj 4 mg/20ml (0.2
mg/ml)
128
glycopyrrolate tab 1 mg
128
glycopyrrolate tab 2 mg
128
glycron tab 1.5mg
37
glycron tab 3mg
37
GLYCRON TAB 4.5MG
37
glycron tab 6mg
37
GLYSET TAB 100MG
33
GLYSET TAB 25MG
33
GLYSET TAB 50MG
33
GOLYTELY SOL
104
GRALISE STAR MIS 300/600
123
GRALISE TAB 300MG
123
GRALISE TAB 600MG
123
granisetron hcl inj 0.1 mg/ml
38
granisetron hcl inj 1 mg/ml
38
granisetron hcl inj 4 mg/4ml (1 mg/ml) 38
granisetron hcl tab 1 mg
38
GRANISOL SOL 2MG/10ML
38
griseofulvin microsize susp 125 mg/5ml 39
griseofulvin microsize tab 500 mg
39
griseofulvin ultramicrosize tab 125 mg 39
griseofulvin ultramicrosize tab 250 mg 39
guaifenesin-codeine liquid 200-10
mg/5ml
78
guanfacine hcl tab 1 mg
44
guanfacine hcl tab 2 mg
44
GUANIDINE TAB 125MG
47
GYNAZOLE-1 CRE 2%
133
GYNOL II GEL 3%
133
H
HALFAN TAB 250MG
47
152
HALFPRIN TAB 162MG EC
7
halobetasol propionate cream 0.05%
85
halobetasol propionate oint 0.05%
85
HALOG CRE 0.1%
85
HALOG OIN 0.1%
85
haloperidol decanoate im soln 100
mg/ml
58
haloperidol decanoate im soln 50 mg/ml 58
haloperidol lactate inj 5 mg/ml
58
haloperidol lactate oral conc 2 mg/ml
58
haloperidol tab 0.5 mg
58
haloperidol tab 1 mg
58
haloperidol tab 10 mg
58
haloperidol tab 2 mg
58
haloperidol tab 20 mg
58
haloperidol tab 5 mg
58
HAVRIX INJ 1440UNIT
133
HAVRIX INJ 720UNIT
133
heather tab 0.35mg
76
hemril-30 sup 30mg
14
heparin sodium (porcine) inj 1000
unit/ml
24
heparin sodium (porcine) inj 10000
unit/ml
24
heparin sodium (porcine) inj 20000
unit/ml
24
heparin sodium (porcine) inj 5000
unit/ml
24
heparin sodium (porcine) pf inj 5000
unit/0.5ml
24
HEXALEN CAP 50MG
48
HIBERIX SOL 10-25MCG
131
HIZENTRA INJ 10/50ML
118
HIZENTRA INJ 1GM/5ML
118
HIZENTRA INJ 2GM/10ML
118
HIZENTRA INJ 4GM/20ML
118
homatropaire sol 5% op
114
homatropine hbr ophth soln 5%
114
HORIZANT TAB 300MG
123
HORIZANT TAB 600MG
123
HUMALOG INJ 100/ML
35
HUMALOG MIX INJ 50/50
35
HUMALOG MIX INJ 50/50KWP
35
HUMALOG MIX INJ 75/25KWP
35
HUMALOG MIX SUS 75/25
35
HUMATROPE INJ 12MG
91
HUMATROPE INJ 24MG
91
HUMATROPE INJ 5MG
91
HUMATROPE INJ 6MG
91
HUMIRA KIT 20MG/0.4
4
HUMIRA KIT 40MG/0.8
4
HUMIRA PEN KIT CROHNS
4
HUMULIN INJ 70/30
35
HUMULIN N INJ U-100
35
HUMULIN N PN INJ U-100
35
HUMULIN PEN INJ 70/30
35
HUMULIN R INJ U-100
35
HUMULIN R INJ U-500
35
HYCAMTIN CAP 0.25MG
55
HYCAMTIN CAP 1MG
55
hydralazine hcl inj 20 mg/ml
47
hydralazine hcl tab 10 mg
47
hydralazine hcl tab 100 mg
47
hydralazine hcl tab 25 mg
47
hydralazine hcl tab 50 mg
47
hydrochlorothiazide cap 12.5 mg
89
hydrochlorothiazide tab 12.5 mg
89
hydrochlorothiazide tab 25 mg
89
hydrochlorothiazide tab 50 mg
89
HYDROCO/APAP SOL 10-325MG
12
hydrocodone w/ homatropine syrup 5-1.5
mg/5ml
78
hydrocodone w/ homatropine tab 5-1.5
mg
78
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
12
hydrocodone-acetaminophen tab 10-300
mg
12
hydrocodone-acetaminophen tab 10-325
mg
12
hydrocodone-acetaminophen tab 2.5-325
mg
12
hydrocodone-acetaminophen tab 5-300
mg
12
hydrocodone-acetaminophen tab 5-325
mg
12
hydrocodone-acetaminophen tab 7.5-300
mg
12
hydrocodone-acetaminophen tab 7.5-325
mg
12
hydrocortisone butyrate cream 0.1%
85
hydrocortisone butyrate hydrophilic lipo
base cream 0.1%
86
hydrocortisone butyrate oint 0.1%
86
hydrocortisone butyrate soln 0.1%
86
hydrocortisone cream 1%
86
hydrocortisone cream 2.5%
86
hydrocortisone enema 100 mg/60ml
14
hydrocortisone lotion 2.5%
86
hydrocortisone oint 1%
86
hydrocortisone oint 2.5%
86
hydrocortisone tab 10 mg
77
hydrocortisone tab 20 mg
77
hydrocortisone tab 5 mg
77
hydrocortisone valerate cream 0.2%
86
hydrocortisone valerate oint 0.2%
86
hydrocortisone w/ acetic acid otic soln 12%
118
hydromet syp 5-1.5/5
78
HYDROMORPHON SUP 3MG
9
hydromorphone hcl liqd 1 mg/ml
9
hydromorphone hcl tab 2 mg
9
hydromorphone hcl tab 4 mg
9
hydromorphone hcl tab 8 mg
9
hydroxychloroquine sulfate tab 200 mg 47
hydroxyurea cap 500 mg
53
hydroxyzine hcl im soln 25 mg/ml
17
hydroxyzine hcl im soln 50 mg/ml
17
hydroxyzine hcl syrup 10 mg/5ml
17
hydroxyzine hcl tab 10 mg
18
hydroxyzine hcl tab 25 mg
18
153
hydroxyzine hcl tab 50 mg
18
hydroxyzine pamoate cap 100 mg
18
hydroxyzine pamoate cap 25 mg
18
hydroxyzine pamoate cap 50 mg
18
hyomax tab 0.125mg
128
hyomax-ft tab 0.125mg
128
hyomax-sl sub 0.125mg
128
hyomax-sr tab 0.375mg
128
hyoscyamine sulfate tab 0.125 mg
128
hyoscyamine sulfate tab disp 0.125 mg128
hyoscyamine sulfate tab sl 0.125 mg 128
hyoscyamine sulfate tab sr 12hr 0.375
mg
128
I
ibandronate sodium iv soln 3 mg/3ml
(base equivalent)
90
ibandronate sodium tab 150 mg (base
equivalent)
90
ibuprofen sus 100/5ml
5
ibuprofen tab 400 mg
5
ibuprofen tab 600 mg
5
ibuprofen tab 800 mg
5
ICAR PEDS SUS GRAPE
103
ICLUSIG TAB 15MG
52
ICLUSIG TAB 45MG
52
idarubicin hcl iv inj 10 mg/10ml (1
mg/ml)
51
idarubicin hcl iv inj 20 mg/20ml (1
mg/ml)
51
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 51
ifosfamide & mesna inj kit 1000-1000
mg
52
ifosfamide for inj 1 gm
48
ifosfamide iv inj 1 gm/20ml (50 mg/ml) 48
ifosfamide iv inj 3 gm/60ml (50 mg/ml) 48
ilotycin oin op
115
IMBRUVICA CAP 140MG
52
imipenem-cilastatin intravenous for soln
250 mg
15
imipenem-cilastatin intravenous for soln
500 mg
15
imipramine hcl tab 10 mg
32
imipramine hcl tab 25 mg
32
imipramine hcl tab 50 mg
32
imipramine pamoate cap 100 mg
32
imipramine pamoate cap 125 mg
32
imipramine pamoate cap 150 mg
32
imipramine pamoate cap 75 mg
32
imiquimod cream 5%
86
IMPLANON IMP 68MG
76
INCIVEK TAB 375MG
62
INCRELEX INJ 40MG/4ML
91
indapamide tab 1.25 mg
89
indapamide tab 2.5 mg
89
INDOCIN SUS 25MG/5ML
6
indomethacin cap 25 mg
6
indomethacin cap 50 mg
6
indomethacin cap cr 75 mg
6
INFANRIX INJ
127
INFERGEN INJ 15MCG
62
INFERGEN INJ 9MCG
62
INFLUENZA A SPR 09 H1N1
133
INLYTA TAB 1MG
52
INLYTA TAB 5MG
52
INSULIN NEEDLES/SYRINGES
107
INTELENCE TAB 100MG
61
INTELENCE TAB 200MG
61
INTELENCE TAB 25MG
61
INTRON-A INJ 10MU
53
INTRON-A INJ 10MU PEN
53
INTRON-A INJ 18MU
53
INTRON-A INJ 25MU
53
INTRON-A INJ 3MU PEN
53
INTRON-A INJ 50MU
53
INTRON-A INJ 5MU PEN
53
introvale tab
73
INTUNIV TAB 1MG
2
INTUNIV TAB 2MG
2
INTUNIV TAB 3MG
2
INTUNIV TAB 4MG
2
INVANZ INJ 1GM
15
INVEGA SUST INJ 117/0.75
57
INVEGA SUST INJ 156MG/ML
57
INVEGA SUST INJ 234/1.5
57
INVEGA SUST INJ 39/0.25
57
INVEGA SUST INJ 78/0.5ML
57
INVEGA TAB 1.5MG
57
INVEGA TAB 3MG
57
INVEGA TAB 6MG
57
INVEGA TAB 9MG
57
INVIRASE CAP 200MG
61
INVIRASE TAB 500MG
61
IOPIDINE SOL 1% OP
115
IPOL INJ INACTIVE
133
ipratropium bromide inhal soln 0.02% 20
ipratropium bromide nasal soln 0.03% (21
mcg/spray)
113
ipratropium bromide nasal soln 0.06% (42
mcg/spray)
113
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
22
irbesartan tab 150 mg
44
irbesartan tab 300 mg
44
irbesartan tab 75 mg
44
irbesartan-hydrochlorothiazide tab 15012.5 mg
46
irbesartan-hydrochlorothiazide tab 30012.5 mg
46
irinotecan hcl inj 100 mg/5ml (20
mg/ml)
55
irinotecan hcl inj 40 mg/2ml (20 mg/ml)55
irinotecan hcl inj 500 mg/25ml (20
mg/ml)
55
ISENTRESS CHW 100MG
61
ISENTRESS CHW 25MG
61
ISENTRESS TAB 400MG
61
ISO HOMATROP SOL 2% OP
114
isochron tab 40mg cr
16
isoditrate tab 40mg er
16
154
ISOLYTE-S INJ
108
isonarif cap
48
isoniazid inj 100 mg/ml
48
isoniazid syrup 50 mg/5ml
48
isoniazid tab 100 mg
48
isoniazid tab 300 mg
48
ISORDIL TAB 40MG
16
isosorbide dinitrate sl tab 2.5 mg
16
isosorbide dinitrate sl tab 5 mg
16
isosorbide dinitrate tab 10 mg
16
isosorbide dinitrate tab 20 mg
16
isosorbide dinitrate tab 30 mg
16
isosorbide dinitrate tab 5 mg
16
isosorbide dinitrate tab cr 40 mg
16
isosorbide mononitrate tab 10 mg
16
isosorbide mononitrate tab 20 mg
16
isosorbide mononitrate tab sr 24hr 120
mg
16
isosorbide mononitrate tab sr 24hr 30
mg
16
isosorbide mononitrate tab sr 24hr 60
mg
16
isradipine cap 2.5 mg
68
isradipine cap 5 mg
68
ISTALOL SOL 0.5% OP
114
itraconazole cap 100 mg
39
J
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JALYN CAP
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
JANUMET TAB 50-1000
JANUMET TAB 50-500MG
JANUMET XR TAB 100-1000
JANUMET XR TAB 50-1000
JANUMET XR TAB 50-500MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JENTADUETO TAB 2.5-1000
JENTADUETO TAB 2.5-500
JENTADUETO TAB 2.5-850
jevantique tab 1mg-5mcg
jinteli tab 1mg-5mcg
jolessa tab
jolivette tab 0.35mg
junel 1.5/30 tab
junel 1/20 tab
52
52
52
52
52
100
23
23
23
23
23
23
23
23
23
34
34
34
34
34
34
34
34
34
34
34
93
93
73
76
74
74
junel fe tab 1.5/30
junel fe tab 1/20
74
74
K
KADCYLA INJ 100MG
52
KADCYLA INJ 160MG
52
KADIAN CAP 130MG CR
9
KADIAN CAP 150MG CR
9
KADIAN CAP 200MG CR
9
KADIAN CAP 40MG CR
9
KADIAN CAP 70MG CR
9
KALETRA SOL
61
KALETRA TAB 100-25MG
61
KALETRA TAB 200-50MG
61
KALYDECO TAB 150MG
124
kanamycin sulfate inj 333 mg/ml
4
kariva tab 28 day
74
kcl 20 meq/l (0.15%) in nacl 0.45% inj108
kcl 20 meq/l (0.15%) in nacl 0.9% inj 108
kcl 40 meq/l (0.3%) in nacl 0.9% inj 108
kelnor tab 1/35
74
KENALOG AER SPRAY
86
KEPIVANCE INJ 6.25MG
54
KETEK TAB 300MG
15
KETEK TAB 400MG
15
ketoconazole cream 2%
83
ketoconazole foam 2%
83
ketoconazole shampoo 2%
83
ketoconazole tab 200 mg
40
ketoprofen cap 50 mg
6
ketoprofen cap 75 mg
6
ketoprofen cap sr 24hr 200 mg
6
ketorolac tromethamine im inj 30 mg/ml 6
ketorolac tromethamine im inj 60 mg/2ml
(30 mg/ml)
6
ketorolac tromethamine inj 15 mg/ml
6
ketorolac tromethamine inj 30 mg/ml
6
ketorolac tromethamine inj 300 mg/10ml
(30 mg/ml)
6
ketorolac tromethamine inj 60 mg/2ml (30
mg/ml)
6
ketorolac tromethamine ophth soln
0.4%
117
ketorolac tromethamine ophth soln
0.5%
117
ketorolac tromethamine tab 10 mg
6
ketotifen fumarate ophth soln 0.025%
(base equiv)
117
KINERET INJ
5
KINRIX INJ
127
kionex sus 15gm/60
65
klor-con 10 tab 10meq er
110
klor-con 8 tab 8meq er
110
KLOR-CON M15 TAB
110
klor-con m20 tab 20meq er
110
KRISTALOSE PAK 10GM
104
KRISTALOSE PAK 20GM
105
kurvelo tab 0.15/30
74
KUVAN TAB 100MG
92
155
L
labetalol hcl iv soln 5 mg/ml
65
labetalol hcl tab 100 mg
65
labetalol hcl tab 200 mg
65
labetalol hcl tab 300 mg
65
laclotion lot 12%
86
LACRISERT MIS 5MG OP
114
lactic acid (ammonium lactate) cream
12%
86
lactic acid (ammonium lactate) lotion
10%
86
lactic acid (ammonium lactate) lotion
12%
86
lactulose solution 10 gm/15ml
105
LAMICTAL CHW 2MG
25
LAMICTAL KIT START 35
25
LAMICTAL KIT START 49
25
LAMICTAL KIT START 98
25
LAMICTAL ODT KIT
25
LAMICTAL ODT TAB 100MG
25
LAMICTAL ODT TAB 200MG
25
LAMICTAL ODT TAB 25MG
25
LAMICTAL ODT TAB 50MG
25
LAMICTAL XR KIT
25
LAMISIL GRA 125MG
39
LAMISIL GRA 187.5MG
39
lamivudine tab 100 mg
61
lamivudine tab 150 mg
61
lamivudine tab 300 mg
61
lamivudine-zidovudine tab 150-300 mg 61
lamotrigine tab 100 mg
25
lamotrigine tab 150 mg
25
lamotrigine tab 200 mg
25
lamotrigine tab 25 mg
25
lamotrigine tab chewable dispersible 25
mg
25
lamotrigine tab chewable dispersible 5
mg
25
lamotrigine tab sr 24hr 100 mg
25
lamotrigine tab sr 24hr 200 mg
25
lamotrigine tab sr 24hr 25 mg
25
lamotrigine tab sr 24hr 250 mg
25
lamotrigine tab sr 24hr 300 mg
25
lamotrigine tab sr 24hr 50 mg
25
LANCETS
107
LANCING DEVICE
107
LANOXIN PED INJ 0.1MG/ML
69
LANOXIN TAB 0.0625MG
69
LANOXIN TAB 0.1875MG
69
lansoprazole cap delayed release 15
mg
129
lansoprazole cap delayed release 30
mg
129
LANTUS INJ 100/ML
35
LANTUS INJ SOLOSTAR
35
LASTACAFT SOL 0.25%
117
latanoprost ophth soln 0.005%
117
LATUDA TAB 120MG
57
LATUDA TAB 20MG
57
LATUDA TAB 40MG
57
LATUDA TAB 60MG
57
LATUDA TAB 80MG
57
lavoclen-4 kit acne wsh
80
lavoclen-4 liq crem wsh
80
lavoclen-8 kit acne wsh
80
lavoclen-8 liq crem wsh
81
LAZANDA SPR 100MCG
9
LAZANDA SPR 400MCG
9
leena tab
74
leflunomide tab 10 mg
6
leflunomide tab 20 mg
7
lessina tab
74
LETAIRIS TAB 10MG
70
LETAIRIS TAB 5MG
70
letrozole tab 2.5 mg
51
leucovorin calcium for inj 100 mg
54
leucovorin calcium for inj 200 mg
54
leucovorin calcium for inj 350 mg
54
leucovorin calcium for inj 50 mg
54
leucovorin calcium inj 10 mg/ml
54
leucovorin calcium tab 10 mg
54
leucovorin calcium tab 15 mg
54
leucovorin calcium tab 25 mg
54
leucovorin calcium tab 5 mg
54
LEUCOVORIN INJ CALCIUM
54
LEUKERAN TAB 2MG
49
LEUKINE INJ 250MCG
102
LEUKINE INJ 500 MCG
102
leuprolide acetate inj kit 5 mg/ml
51
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv)
22
levalbuterol hcl soln nebu 0.63 mg/3ml
(base equiv)
22
levalbuterol hcl soln nebu 1.25 mg/3ml
(base equiv)
22
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
22
LEVATOL TAB 20MG
66
LEVEMIR INJ
35
LEVEMIR INJ FLEXPEN
35
LEVETIRACETA INJ 10MG/ML
25
LEVETIRACETA INJ 15MG/ML
25
LEVETIRACETA INJ 5MG/ML
25
levetiracetam inj 500 mg/5ml (100
mg/ml)
25
levetiracetam oral soln 100 mg/ml
25
levetiracetam tab 1000 mg
25
levetiracetam tab 250 mg
25
levetiracetam tab 500 mg
25
levetiracetam tab 750 mg
25
levetiracetam tab sr 24hr 500 mg
25
levetiracetam tab sr 24hr 750 mg
25
levobunolol hcl ophth soln 0.25%
114
levobunolol hcl ophth soln 0.5%
114
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
40
levocetirizine dihydrochloride tab 5 mg 40
levofloxacin in d5w iv soln 250 mg/50ml98
levofloxacin in d5w iv soln 500
mg/100ml
98
156
levofloxacin in d5w iv soln 750
mg/150ml
98
levofloxacin iv soln 25 mg/ml
98
levofloxacin ophth soln 0.5%
115
levofloxacin oral soln 25 mg/ml
98
levofloxacin tab 250 mg
98
levofloxacin tab 500 mg
98
levofloxacin tab 750 mg
98
levonest tab
74
levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)
74
levonorgestrel & ethinyl estradiol (91-day)
tab 0.15-0.03 mg
74
levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg
74
levonorgestrel tab 0.75 mg
75
levora-28 tab 0.15/30
74
levorphanol tartrate tab 2 mg
9
levothroid tab 100mcg
125
levothroid tab 112mcg
125
levothroid tab 125mcg
125
levothroid tab 137mcg
126
levothroid tab 150mcg
126
levothroid tab 175mcg
126
levothroid tab 200mcg
126
levothroid tab 25mcg
125
levothroid tab 300mcg
126
levothroid tab 50mcg
125
levothroid tab 75mcg
125
levothroid tab 88mcg
125
levothyroxine sodium tab 100 mcg
126
levothyroxine sodium tab 112 mcg
126
levothyroxine sodium tab 125 mcg
126
levothyroxine sodium tab 137 mcg
126
levothyroxine sodium tab 150 mcg
126
levothyroxine sodium tab 175 mcg
126
levothyroxine sodium tab 200 mcg
126
levothyroxine sodium tab 25 mcg
126
levothyroxine sodium tab 300 mcg
126
levothyroxine sodium tab 50 mcg
126
levothyroxine sodium tab 75 mcg
126
levothyroxine sodium tab 88 mcg
126
levoxyl tab 100mcg
126
levoxyl tab 112mcg
126
levoxyl tab 125mcg
126
levoxyl tab 137mcg
126
levoxyl tab 150mcg
126
levoxyl tab 175mcg
126
levoxyl tab 200mcg
126
levoxyl tab 25mcg
126
levoxyl tab 50mcg
126
levoxyl tab 75mcg
126
levoxyl tab 88mcg
126
LEXIVA SUS 50MG/ML
61
LEXIVA TAB 700MG
61
LIDO/DEXTROS INJ 5-7.5%
105
lidocaine hcl cream 3%
87
lidocaine hcl gel 2%
87
lidocaine hcl iv inj 10 mg/ml
19
lidocaine hcl iv inj 20 mg/ml
19
lidocaine hcl laryngotracheal soln 4% 110
lidocaine hcl local inj 0.5%
105
lidocaine hcl local inj 1%
105
lidocaine hcl local inj 1.5%
105
lidocaine hcl local inj 2%
105
lidocaine hcl local inj 4%
105
lidocaine hcl local preservative free (pf) inj
0.5%
105
lidocaine hcl local preservative free (pf) inj
1%
105
lidocaine hcl local preservative free (pf) inj
2%
105
lidocaine hcl lotion 3%
87
lidocaine hcl soln 4%
87
lidocaine hcl viscous soln 2%
110
lidocaine iv infusion in d5w inj 4 mg/ml 19
lidocaine iv infusion in d5w inj 8 mg/ml 19
lidocaine oint 5%
87
lidocaine patch 5%
87
lidocaine-prilocaine cream 2.5-2.5%
87
lidocaine-prilocaine kit 2.5-2.5%
87
LINCOCIN INJ 300MG/ML
16
lindane lotion 1%
87
lindane shampoo 1%
87
liothyronine sodium iv soln 10 mcg/ml 126
liothyronine sodium tab 25 mcg
126
liothyronine sodium tab 5 mcg
126
liothyronine sodium tab 50 mcg
126
lipodox 50 inj 2mg/ml
51
lipodox inj 2mg/ml
52
lisinopril & hydrochlorothiazide tab 1012.5 mg
46
lisinopril & hydrochlorothiazide tab 2012.5 mg
46
lisinopril & hydrochlorothiazide tab 20-25
mg
46
lisinopril tab 10 mg
43
lisinopril tab 2.5 mg
43
lisinopril tab 20 mg
43
lisinopril tab 30 mg
43
lisinopril tab 40 mg
43
lisinopril tab 5 mg
43
lithium carbonate cap 150 mg
57
lithium carbonate cap 300 mg
57
lithium carbonate cap 600 mg
57
lithium carbonate tab 300 mg
57
lithium carbonate tab cr 300 mg
57
lithium carbonate tab cr 450 mg
57
LITHIUM CITR SOL 8MEQ/5ML
57
LIVALO TAB 1MG
42
LIVALO TAB 2MG
42
LIVALO TAB 4MG
42
LO LOESTRIN TAB
74
LO MINASTRIN PAK FE
74
lokara lot 0.05%
86
lomedia 24 tab fe
74
lomustine cap 10 mg
49
lomustine cap 100 mg
49
lomustine cap 40 mg
49
loperamide hcl cap 2 mg
37
157
lorazepam conc 2 mg/ml
19
lorazepam tab 0.5 mg
19
lorazepam tab 1 mg
19
lorazepam tab 2 mg
19
loryna tab 3-0.02mg
74
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg
46
losartan potassium & hydrochlorothiazide
tab 100-25 mg
46
losartan potassium & hydrochlorothiazide
tab 50-12.5 mg
46
losartan potassium tab 100 mg
44
losartan potassium tab 25 mg
44
losartan potassium tab 50 mg
44
LOTEMAX GEL 0.5%
116
LOTEMAX OIN 0.5%
116
LOTEMAX SUS 0.5%
116
LOTRONEX TAB 0.5MG
99
LOTRONEX TAB 1MG
99
lovastatin tab 10 mg
42
lovastatin tab 20 mg
42
lovastatin tab 40 mg
42
LOVAZA CAP 1GM
41
low-ogestrel tab
74
loxapine succinate cap 10 mg
58
loxapine succinate cap 25 mg
58
loxapine succinate cap 5 mg
58
loxapine succinate cap 50 mg
58
ludent chw 0.25mg f
109
ludent chw 0.5mg f
109
ludent chw 1mg f
109
LUFYLLIN TAB 200MG
22
LUFYLLIN TAB 400MG
22
LUMIGAN SOL 0.01%
117
LUMIGAN SOL 0.03%
117
LUNESTA TAB 1MG
104
LUNESTA TAB 2MG
104
LUNESTA TAB 3MG
104
LUPR DEP-PED INJ 11.25MG
91
LUPR DEP-PED INJ 15MG
91
LUPR DEP-PED INJ 30MG
91
LUPR DEP-PED INJ 7.5MG
91
LUPRON DEPOT INJ 11.25MG
51
LUPRON DEPOT INJ 22.5MG
51
LUPRON DEPOT INJ 3.75MG
51
LUPRON DEPOT INJ 30MG
51
LUPRON DEPOT INJ 45MG
51
LUPRON DEPOT INJ 7.5MG
51
LURIDE CHW 0.25MG F
109
LURIDE CHW 0.5MG F
109
LURIDE DRO 0.5MG/ML
109
lutera tab
74
LYRICA CAP 100MG
26
LYRICA CAP 150MG
26
LYRICA CAP 200MG
26
LYRICA CAP 225MG
26
LYRICA CAP 25MG
26
LYRICA CAP 300MG
26
LYRICA CAP 50MG
26
LYRICA CAP 75MG
26
LYRICA SOL 20MG/ML
LYSODREN TAB 500MG
26
51
M
M-M-R II INJ LIVE
133
MACRODANTIN CAP 25MG
130
mafenide acetate packet for topical soln
5% (50 gm)
84
MAGNESIUM SU INJ 40MG/ML
109
MAGNESIUM SU INJ 80MG/ML
109
magnesium sulfate inj 50%
109
malathion lotion 0.5%
87
maprotiline hcl tab 25 mg
28
maprotiline hcl tab 50 mg
28
maprotiline hcl tab 75 mg
28
marlissa tab 0.15/30
74
MARPLAN TAB 10MG
28
MATULANE CAP 50MG
53
matzim la tab 180mg/24
68
matzim la tab 240mg/24
68
matzim la tab 300mg/24
68
matzim la tab 360mg/24
68
matzim la tab 420mg/24
68
MAXIDEX SUS 0.1% OP
116
MAXIPIME INJ 1GM
73
MAXIPIME INJ 2GM
73
mebendazole chew tab 100 mg
14
meclizine hcl tab 12.5 mg
38
meclizine hcl tab 25 mg
38
meclofenamate sodium cap 100 mg
6
meclofenamate sodium cap 50 mg
6
MEDROL TAB 2MG
77
medroxyprogesterone acetate im susp 150
mg/ml
76
medroxyprogesterone acetate tab 10
mg
121
medroxyprogesterone acetate tab 2.5
mg
121
medroxyprogesterone acetate tab 5
mg
121
mefenamic acid cap 250 mg
6
mefloquine hcl tab 250 mg
47
MEFOXIN INJ 1GM/50ML
71
MEFOXIN INJ 2GM/50ML
71
MEGACE ES SUS 625/5ML
121
megestrol acetate susp 40 mg/ml
51
megestrol acetate tab 20 mg
51
megestrol acetate tab 40 mg
51
MEKINIST TAB 0.5MG
52
MEKINIST TAB 2MG
52
meloxicam susp 7.5 mg/5ml
6
meloxicam tab 15 mg
6
meloxicam tab 7.5 mg
6
melphalan hcl for inj 50 mg (base
equiv)
49
MENACTRA INJ
131
MENEST TAB 0.3MG
96
MENEST TAB 0.625MG
96
MENEST TAB 1.25MG
96
MENEST TAB 2.5MG
96
158
MENHIBRIX INJ
131
MENOMUNE INJ A/C/Y/W
131
MENOSTAR DIS 14MCG
97
MENTAX CRE 1%
83
MENVEO INJ
131
meperidine hcl oral soln 50 mg/5ml
9
meperidine hcl tab 100 mg
9
meperidine hcl tab 50 mg
9
MEPHYTON TAB 5MG
134
meprobamate tab 200 mg
18
meprobamate tab 400 mg
18
MEPRON SUS
15
mercaptopurine tab 50 mg
50
meropenem iv for soln 1 gm
15
meropenem iv for soln 500 mg
15
mesalamine enema 4 gm
99
mesalamine rectal enema 4 gm & cleanser
wipe kit
99
mesna inj 100 mg/ml
54
MESNEX TAB 400MG
54
MESTINON SYP 60MG/5ML
47
MESTINON TAB TIMESPAN
47
metadate tab 20mg er
3
metaproterenol sulfate syrup 10
mg/5ml
22
metaproterenol sulfate tab 10 mg
22
metaproterenol sulfate tab 20 mg
22
metaxalone tab 800 mg
112
metformin hcl tab 1000 mg
34
metformin hcl tab 500 mg
34
metformin hcl tab 850 mg
34
metformin hcl tab sr 24hr 500 mg
34
metformin hcl tab sr 24hr 750 mg
34
metformin hcl tab sr 24hr osmotic 1000
mg
34
metformin hcl tab sr 24hr osmotic 500
mg
34
methadone hcl conc 10 mg/ml
9
methadone hcl soln 10 mg/5ml
9
methadone hcl soln 5 mg/5ml
9
methadone hcl tab 10 mg
9
methadone hcl tab 5 mg
9
methadone hcl tab for oral susp 40 mg 9
METHADONE INJ 10MG/ML
9
methadose tab 10mg
9
methadose tab 40mg
9
methadose tab 5mg
9
methamphetamine hcl tab 5 mg
1
methazolamide tab 25 mg
88
methazolamide tab 50 mg
88
methenamine hippurate tab 1 gm
130
methimazole tab 10 mg
125
methimazole tab 5 mg
125
methocarbamol tab 500 mg
112
methocarbamol tab 750 mg
112
methotrexate sodium for inj 1 gm
50
methotrexate sodium inj 25 mg/ml
50
methotrexate sodium inj pf 25 mg/ml 50
methotrexate sodium tab 2.5 mg (base
equiv)
50
methscopolamine bromide tab 2.5 mg 128
methscopolamine bromide tab 5 mg
128
methyclothiazide tab 5 mg
89
methyldopa tab 250 mg
45
methyldopa tab 500 mg
45
methyldopate hcl inj 250 mg/5ml
45
METHYLIN CHW 10MG
3
METHYLIN CHW 2.5MG
3
METHYLIN CHW 5MG
3
methylin tab 10mg
3
methylin tab 10mg er
3
methylin tab 20mg
3
methylin tab 20mg er
3
methylin tab 5mg
3
methylphenidate hcl cap cr 10 mg
3
methylphenidate hcl cap cr 20 mg
3
methylphenidate hcl cap cr 30 mg
3
methylphenidate hcl cap cr 40 mg
3
methylphenidate hcl cap cr 50 mg
3
methylphenidate hcl cap cr 60 mg
3
methylphenidate hcl cap sr 24hr 20 mg 3
methylphenidate hcl cap sr 24hr 30 mg 3
methylphenidate hcl cap sr 24hr 40 mg 3
methylphenidate hcl soln 10 mg/5ml
3
methylphenidate hcl soln 5 mg/5ml
3
methylphenidate hcl tab 10 mg
3
methylphenidate hcl tab 20 mg
3
methylphenidate hcl tab 5 mg
3
methylphenidate hcl tab cr 10 mg
3
methylphenidate hcl tab cr 20 mg
3
methylphenidate hcl tab sa osm 18 mg 3
methylphenidate hcl tab sa osm 27 mg 3
methylphenidate hcl tab sa osm 36 mg 3
methylphenidate hcl tab sa osm 54 mg 3
methylprednisolone sodium succinate for
inj 1000 mg
77
methylprednisolone sodium succinate for
inj 125 mg
77
methylprednisolone sodium succinate for
inj 40 mg
77
methylprednisolone sodium succinate for
inj 500 mg
77
methylprednisolone tab 16 mg
77
methylprednisolone tab 32 mg
77
methylprednisolone tab 4 mg
77
methylprednisolone tab 4 mg dose pack 77
methylprednisolone tab 8 mg
77
metipranolol ophth soln 0.3%
114
metoclopramide hcl inj 5 mg/ml
99
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)
99
metoclopramide hcl tab 10 mg
99
metoclopramide hcl tab 5 mg
99
metolazone tab 10 mg
89
metolazone tab 2.5 mg
89
metolazone tab 5 mg
89
metoprolol & hydrochlorothiazide tab 10025 mg
46
metoprolol & hydrochlorothiazide tab 10050 mg
46
159
metoprolol & hydrochlorothiazide tab 5025 mg
46
metoprolol succinate tab sr 24hr 100
mg
66
metoprolol succinate tab sr 24hr 200
mg
66
metoprolol succinate tab sr 24hr 25 mg 66
metoprolol succinate tab sr 24hr 50 mg 66
metoprolol tartrate inj 1 mg/ml
66
metoprolol tartrate tab 100 mg
66
metoprolol tartrate tab 25 mg
66
metoprolol tartrate tab 50 mg
66
METOZOLV ODT TAB 10MG
99
METOZOLV ODT TAB 5MG
99
metronidazole cap 375 mg
14
metronidazole cream 0.75%
87
metronidazole gel 0.75%
87
metronidazole gel 1%
87
metronidazole in nacl 0.79% iv soln 500
mg/100ml
14
metronidazole lotion 0.75%
87
metronidazole tab 250 mg
14
metronidazole tab 500 mg
14
metronidazole vaginal gel 0.75%
133
mexiletine hcl cap 150 mg
19
mexiletine hcl cap 200 mg
19
mexiletine hcl cap 250 mg
19
MG SO4/D5W INJ 10MG/ML
110
MG SO4/D5W INJ 20MG/ML
110
MIACALCIN INJ 200/ML
90
miconazole 3 sup 200mg
133
microgestin tab 1.5/30
74
microgestin tab 1/20
74
microgestin tab fe 1/20
74
microgestin tab fe1.5/30
74
midodrine hcl tab 10 mg
134
midodrine hcl tab 2.5 mg
134
midodrine hcl tab 5 mg
134
MILLIPRED DP PAK 5MG
77
MILLIPRED SOL 10MG/5ML
77
MILLIPRED TAB 5MG
77
mimvey tab 1-0.5mg
93
MINASTRIN 24 CHW FE
74
minirin spr nasal
92
minitran dis 0.1mg/hr
16
minitran dis 0.2mg/hr
17
minitran dis 0.4mg/hr
17
minitran dis 0.6mg/hr
17
minocycline hcl cap 100 mg
125
minocycline hcl cap 50 mg
125
minocycline hcl cap 75 mg
125
minocycline hcl tab 100 mg
125
minocycline hcl tab 50 mg
125
minocycline hcl tab 75 mg
125
minocycline hcl tab sr 24hr 135 mg
125
minocycline hcl tab sr 24hr 45 mg
125
minocycline hcl tab sr 24hr 90 mg
125
minoxidil tab 10 mg
47
minoxidil tab 2.5 mg
47
MIRAPEX ER TAB 0.375MG
56
MIRAPEX ER TAB 0.75MG
56
MIRAPEX ER TAB 1.5MG
56
MIRAPEX ER TAB 2.25MG
56
MIRAPEX ER TAB 3.75MG
56
MIRAPEX ER TAB 3MG
56
MIRAPEX ER TAB 4.5MG
56
MIRENA IUD SYSTEM
75
mirtazapine orally disintegrating tab 15
mg
27
mirtazapine orally disintegrating tab 30
mg
27
mirtazapine orally disintegrating tab 45
mg
28
mirtazapine tab 15 mg
28
mirtazapine tab 30 mg
28
mirtazapine tab 45 mg
28
mirtazapine tab 7.5 mg
28
misoprostol tab 100 mcg
130
misoprostol tab 200 mcg
130
mitomycin for inj 20 mg
52
mitomycin for inj 40 mg
52
mitomycin for inj 5 mg
52
mitoxantrone hcl inj conc 20 mg/10ml (2
mg/ml)
52
mitoxantrone hcl inj conc 25 mg/12.5ml (2
mg/ml)
52
mitoxantrone hcl inj conc 30 mg/15ml (2
mg/ml)
52
modafinil tab 100 mg
3
modafinil tab 200 mg
3
moexipril hcl tab 15 mg
43
moexipril hcl tab 7.5 mg
43
mometasone furoate cream 0.1%
86
mometasone furoate oint 0.1%
86
mometasone furoate solution 0.1%
(lotion)
86
mono-linyah tab 0.25-35
74
mononessa tab
74
montelukast sodium chew tab 4 mg (base
equiv)
20
montelukast sodium chew tab 5 mg (base
equiv)
20
montelukast sodium oral granules packet
4 mg (base equiv)
20
montelukast sodium tab 10 mg (base
equiv)
20
MONUROL PAK GRANULES
130
morgidox cap 1x100mg
125
MORPHINE SUL INJ 150/30ML
9
MORPHINE SUL INJ 2MG/ML
9
MORPHINE SUL INJ 4MG/ML
9
MORPHINE SUL INJ 5MG/ML
9
MORPHINE SUL INJ 8MG/ML
9
MORPHINE SUL SUP 30MG
9
morphine sulfate (concentrate) oral soln
20 mg/ml
9
morphine sulfate beads cap sr 24hr 120
mg
10
morphine sulfate beads cap sr 24hr 30
mg
10
morphine sulfate beads cap sr 24hr 45
160
mg
morphine sulfate beads cap sr 24hr 60
mg
morphine sulfate beads cap sr 24hr 75
mg
morphine sulfate beads cap sr 24hr 90
mg
morphine sulfate cap sr 24hr 10 mg
morphine sulfate cap sr 24hr 100 mg
morphine sulfate cap sr 24hr 20 mg
morphine sulfate cap sr 24hr 30 mg
morphine sulfate cap sr 24hr 50 mg
morphine sulfate cap sr 24hr 60 mg
morphine sulfate cap sr 24hr 80 mg
morphine sulfate inj 10 mg/ml
morphine sulfate inj 15 mg/ml
morphine sulfate inj 2 mg/ml
morphine sulfate inj 8 mg/ml
morphine sulfate inj pf 0.5 mg/ml
morphine sulfate inj pf 1 mg/ml
morphine sulfate iv soln 1 mg/ml
morphine sulfate iv soln 25 mg/ml
morphine sulfate iv soln 50 mg/ml
morphine sulfate iv soln pf 10 mg/ml
morphine sulfate iv soln pf 15 mg/ml
morphine sulfate oral soln 10 mg/5ml
morphine sulfate oral soln 20 mg/5ml
morphine sulfate suppos 10 mg
morphine sulfate suppos 20 mg
morphine sulfate suppos 5 mg
morphine sulfate tab 15 mg
morphine sulfate tab 30 mg
morphine sulfate tab cr 100 mg
morphine sulfate tab cr 15 mg
morphine sulfate tab cr 200 mg
morphine sulfate tab cr 30 mg
morphine sulfate tab cr 60 mg
MOTOFEN TAB
MOVIPREP SOL
MOXEZA SOL 0.5%
moxifloxacin hcl tab 400 mg (base
equiv)
MOZOBIL INJ
MULTAQ TAB 400MG
MULTI-VIT/FE DRO /FL 0.25
multi-vit/fl chw 0.25mg
multi-vit/fl chw 0.5mg
multi-vit/fl chw 1mg
MULTI-VIT/FL DRO /FE 0.25
multi-vit/fl dro 0.25mg
multi-vit/fl dro 0.5mg/ml
multivit/fl chw 0.25mg
multivit/fl chw 0.5mg
multivit/fl chw 1mg
mupirocin oint 2%
MYCAMINE INJ 100MG
MYCAMINE INJ 50MG
MYCOBUTIN CAP 150MG
mycophenolate mofetil cap 250 mg
mycophenolate mofetil tab 500 mg
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
37
104
115
98
103
20
111
111
111
111
111
111
111
111
111
111
82
39
39
48
64
64
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)
64
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)
64
MYKIDZ IRON SUS 15/1.5ML
103
MYLERAN TAB 2MG
49
myorisan cap 10mg
81
myorisan cap 20mg
81
myorisan cap 40mg
81
MYOZYME INJ 50MG
92
MYRBETRIQ TAB 25MG
131
MYRBETRIQ TAB 50MG
131
MYTELASE TAB 10MG
47
myzilra tab
74
N
nabumetone tab 500 mg
6
nabumetone tab 750 mg
6
nadolol & bendroflumethiazide tab 40-5
mg
46
nadolol & bendroflumethiazide tab 80-5
mg
46
nadolol tab 160 mg
66
nadolol tab 20 mg
66
nadolol tab 40 mg
66
nadolol tab 80 mg
66
nafcillin sodium for inj 1 gm
121
nafcillin sodium for inj 10 gm
121
nafcillin sodium for inj 2 gm
121
nafcillin sodium for iv soln 1 gm
121
nafcillin sodium for iv soln 2 gm
121
nafrinse chw 1mg f
109
NAFTIN CRE 1%
83
NAFTIN CRE 2%
83
NAFTIN GEL 1%
83
NAFTIN GEL 2%
83
NAGLAZYME INJ 1MG/ML
92
nalbuphine hcl inj 10 mg/ml
13
nalbuphine hcl inj 20 mg/ml
13
NALFON CAP 200MG
6
NALFON CAP 400MG
6
NALLPEN/DEX INJ 1GM/50ML
121
NALLPEN/DEX INJ 2GM/100
121
naloxone hcl inj 0.4 mg/ml
37
naloxone hcl inj 1 mg/ml
37
naltrexone hcl tab 50 mg
37
NAMENDA SOL 10MG/5ML
122
NAMENDA TAB 10MG
122
NAMENDA TAB 5-10MG
122
NAMENDA TAB 5MG
122
naphazoline hcl ophth soln 0.1%
116
naproxen dr tab 375mg
6
naproxen dr tab 500mg
6
naproxen sodium tab 275 mg
6
naproxen sodium tab 550 mg
6
naproxen susp 125 mg/5ml
6
naproxen tab 250 mg
6
naproxen tab 375 mg
6
naproxen tab 500 mg
6
naratriptan hcl tab 1 mg (base equiv) 107
161
naratriptan hcl tab 2.5 mg (base
equiv)
107
NASONEX SPR 50MCG/AC
113
NATACYN SUS 5% OP
115
NATAZIA TAB
74
nateglinide tab 120 mg
36
nateglinide tab 60 mg
35
NAVANE CAP 20MG
60
NEBUPENT INH 300MG
14
necon tab 0.5/35
74
necon tab 1/35
74
necon tab 1/50-28
74
NECON TAB 10/11-28
74
necon tab 7/7/7
74
nefazodone hcl tab 100 mg
28
nefazodone hcl tab 150 mg
28
nefazodone hcl tab 200 mg
28
nefazodone hcl tab 250 mg
28
nefazodone hcl tab 50 mg
28
NEO-FRADIN SOL 125/5ML
4
neo-polycin oin hc 1%op
116
neomycin sulfate tab 500 mg
4
neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml
115
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
116
neomycin-polymyxin-dexamethasone
ophth susp 0.1%
116
neomycin-polymyxin-hc ophth susp
116
neomycin-polymyxin-hc otic soln 1% 117
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
118
NEULASTA INJ 6MG/0.6M
102
NEUPOGEN INJ 300/0.5
102
NEUPOGEN INJ 300MCG
102
NEUPOGEN INJ 480/0.8
102
NEUPOGEN INJ 480MCG
102
NEVANAC SUS 0.1%
117
nevirapine susp 50 mg/5ml
61
nevirapine tab 200 mg
61
NEXAVAR TAB 200MG
52
NEXIUM CAP 20MG
129
NEXIUM CAP 40MG
129
NEXIUM GRA 10MG DR
129
NEXIUM GRA 2.5MG DR
129
NEXIUM GRA 20MG DR
129
NEXIUM GRA 40MG DR
129
NEXIUM GRA 5MG DR
129
NEXPLANON IMP 68MG
76
next choice tab 0.75mg
75
next choice tab 1.5mg
75
NEXTERONE INJ
20
niacin tab cr 1000 mg
(antihyperlipidemic)
43
niacin tab cr 500 mg
(antihyperlipidemic)
43
niacin tab cr 750 mg
(antihyperlipidemic)
43
nicardipine hcl cap 20 mg
68
nicardipine hcl cap 30 mg
68
nicardipine hcl iv soln 2.5 mg/ml
68
nicotine polacrilex gum 2 mg
123
nicotine polacrilex gum 4 mg
123
nicotine polacrilex lozenge 2 mg
123
nicotine polacrilex lozenge 4 mg
124
nicotine td patch 24hr 14 mg/24hr
124
nicotine td patch 24hr 21 mg/24hr
124
nicotine td patch 24hr 7 mg/24hr
124
NICOTROL INH
124
NICOTROL NS SPR 10MG/ML
124
nifediac cc tab 30mg er
68
nifediac cc tab 60mg er
68
nifediac cc tab 90mg er
68
nifedical xl tab 30mg
68
nifedical xl tab 60mg
68
nifedipine tab sr 24hr 30 mg
68
nifedipine tab sr 24hr 60 mg
69
nifedipine tab sr 24hr 90 mg
69
nifedipine tab sr 24hr osmotic 30 mg
69
nifedipine tab sr 24hr osmotic 60 mg
69
nifedipine tab sr 24hr osmotic 90 mg
69
NILANDRON TAB 150MG
51
nimodipine cap 30 mg
69
nisoldipine tab sr 24hr 17 mg
69
nisoldipine tab sr 24hr 20 mg
69
nisoldipine tab sr 24hr 25.5 mg
69
nisoldipine tab sr 24hr 30 mg
69
nisoldipine tab sr 24hr 34 mg
69
nisoldipine tab sr 24hr 40 mg
69
nisoldipine tab sr 24hr 8.5 mg
69
NITRO-BID OIN 2%
17
NITRO-DUR DIS 0.3MG/HR
17
NITRO-DUR DIS 0.8MG/HR
17
nitrofurantoin macrocrystalline cap 100
mg
130
nitrofurantoin macrocrystalline cap 50
mg
130
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
130
nitrofurantoin susp 25 mg/5ml
131
NITROGLYCER INJ 5MG/ML
17
nitroglycerin cap cr 2.5 mg
17
nitroglycerin cap cr 6.5 mg
17
nitroglycerin cap cr 9 mg
17
nitroglycerin iv soln 100 mcg/ml in d5w 17
nitroglycerin iv soln 200 mcg/ml in d5w 17
nitroglycerin iv soln 400 mcg/ml in d5w 17
nitroglycerin td patch 24hr 0.1 mg/hr
17
nitroglycerin td patch 24hr 0.2 mg/hr
17
nitroglycerin td patch 24hr 0.4 mg/hr
17
nitroglycerin td patch 24hr 0.6 mg/hr
17
nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
17
NITROMIST AER 400MCG
17
NITROSTAT SUB 0.3MG
17
NITROSTAT SUB 0.4MG
17
NITROSTAT SUB 0.6MG
17
nizatidine cap 150 mg
128
nizatidine cap 300 mg
128
nizatidine oral soln 15 mg/ml
128
162
nora-be tab 0.35mg
76
NORDITROPIN INJ 10/1.5ML
91
NORDITROPIN INJ 15/1.5ML
91
NORDITROPIN INJ 30/3ML
91
NORDITROPIN INJ 5/1.5ML
91
norethindrone acetate tab 5 mg
121
norethindrone tab 0.35 mg
76
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg
74
norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg
74
norgestrel & ethinyl estradiol tab 0.3 mg30 mcg
74
NORMOSOL -R INJ
108
NOROXIN TAB 400MG
98
NORPACE CAP 100MG CR
19
NORPACE CAP 150MG CR
19
nortrel tab 0.5/35
74
nortrel tab 1/35
75
nortrel tab 7/7/7
75
nortriptyline hcl cap 10 mg
32
nortriptyline hcl cap 25 mg
32
nortriptyline hcl cap 50 mg
32
nortriptyline hcl cap 75 mg
32
nortriptyline hcl soln 10 mg/5ml
33
NORVIR CAP 100MG
61
NORVIR SOL 80MG/ML
61
NORVIR TAB 100MG
61
novarel inj 10000unt
90
NOVOLIN INJ 70/30
35
NOVOLIN N INJ U-100
35
NOVOLIN R INJ U-100
35
NOVOLOG INJ 100/ML
35
NOVOLOG INJ PENFILL
35
NOVOLOG MIX INJ 70/30
35
NOVOLOG MIX INJ FLEXPEN
35
NOXAFIL SUS 40MG/ML
40
NOXAFIL TAB 100MG
40
NUCYNTA ER TAB 100MG
10
NUCYNTA ER TAB 150MG
10
NUCYNTA ER TAB 200MG
10
NUCYNTA ER TAB 250MG
10
NUCYNTA ER TAB 50MG
10
NUCYNTA TAB 100MG
11
NUCYNTA TAB 50MG
10
NUCYNTA TAB 75MG
10
NUEDEXTA CAP 20-10MG
123
nulev tab 0.125mg
128
NULOJIX INJ 250MG
64
NUTROPIN AQ INJ 10MG/2ML
91
NUTROPIN AQ INJ 20MG/2ML
91
NUTROPIN AQ INJ NUSPIN 5
91
NUTROPIN INJ 10MG
91
NUVARING MIS
75
NUVIGIL TAB 150MG
4
NUVIGIL TAB 200MG
4
NUVIGIL TAB 250MG
4
NUVIGIL TAB 50MG
4
nyamyc pow 100000
83
nystatin cream 100000 unit/gm
83
nystatin oint 100000 unit/gm
83
nystatin oral powder
39
nystatin susp 100000 unit/ml
110
nystatin tab 500000 unit
39
nystatin topical powder
83
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
83
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
83
nystop pow 100000
83
O
ocella tab 3-0.03mg
75
OCTAGAM INJ 10GM
118
OCTAGAM INJ 1GM
118
OCTAGAM INJ 25GM
118
OCTAGAM INJ 5GM
118
octreotide acetate inj 100 mcg/ml (0.1
mg/ml)
93
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
93
octreotide acetate inj 200 mcg/ml (0.2
mg/ml)
93
octreotide acetate inj 50 mcg/ml (0.05
mg/ml)
93
octreotide acetate inj 500 mcg/ml (0.5
mg/ml)
93
ofloxacin ophth soln 0.3%
115
ofloxacin otic soln 0.3%
117
ofloxacin tab 200 mg
98
ofloxacin tab 300 mg
98
ofloxacin tab 400 mg
98
ogestrel tab
75
olanzapine for im inj 10 mg
58
olanzapine orally disintegrating tab 10
mg
58
olanzapine orally disintegrating tab 15
mg
58
olanzapine orally disintegrating tab 20
mg
58
olanzapine orally disintegrating tab 5
mg
58
olanzapine tab 10 mg
59
olanzapine tab 15 mg
59
olanzapine tab 2.5 mg
58
olanzapine tab 20 mg
59
olanzapine tab 5 mg
59
olanzapine tab 7.5 mg
59
OLYSIO CAP 150MG
62
omeprazole cap delayed release 10 mg 129
omeprazole cap delayed release 20 mg 129
omeprazole cap delayed release 40 mg 130
omeprazole-sodium bicarbonate cap 201100 mg
130
omeprazole-sodium bicarbonate cap 401100 mg
130
OMNIFLEX DPR
106
OMNITROPE INJ 10/1.5ML
91
OMNITROPE INJ 5.8MG
91
OMNITROPE INJ 5/1.5ML
91
163
OMONTYS INJ 10MG/ML
102
OMONTYS INJ 20MG/2ML
102
ONCASPAR INJ 750/ML
53
ondansetron hcl
and dextrose inj 32 mg/50ml
38
ondansetron hcl inj 4 mg/2ml (2 mg/ml)38
ondansetron hcl inj 40 mg/20ml (2
mg/ml)
38
ondansetron hcl oral soln 4 mg/5ml
38
ondansetron hcl tab 24 mg
38
ondansetron hcl tab 4 mg
38
ondansetron hcl tab 8 mg
38
ondansetron orally disintegrating tab 4
mg
38
ondansetron orally disintegrating tab 8
mg
38
ONETOUCH BLOOD GLUCOSE TEST
KITS
107
ONETOUCH BLOOD GLUCOSE TEST
STRIPS
107
ONFI SUS 2.5MG/ML
24
ONFI TAB 10MG
24
ONFI TAB 20MG
24
ONFI TAB 5MG
24
ONGLYZA TAB 2.5MG
35
ONGLYZA TAB 5MG
35
ONTAK INJ 150/ML
54
OPANA ER TAB 10MG
11
OPANA ER TAB 15MG
11
OPANA ER TAB 20MG
11
OPANA ER TAB 30MG
11
OPANA ER TAB 40MG
11
OPANA ER TAB 5MG
11
OPANA ER TAB 7.5MG
11
oralone pst 0.1%
111
ORAP TAB 1MG
123
ORAP TAB 2MG
123
ORAPRED ODT TAB 10MG
77
ORAPRED ODT TAB 15MG
77
ORAPRED ODT TAB 30MG
77
ORAVIG TAB 50MG
110
ORENCIA INJ 125MG/ML
7
ORENCIA INJ 250MG
7
ORFADIN CAP 10MG
92
ORFADIN CAP 2MG
92
ORFADIN CAP 5MG
92
orphen cpd tab ds
113
orphenadrine citrate inj 30 mg/ml
113
orphenadrine citrate tab sr 12hr 100
mg
113
orphenadrine w/ aspirin & caffeine tab 25385-30 mg
113
orsythia tab
75
ORTHO COIL DPR KIT 100
106
ORTHO COIL DPR KIT 105
106
ORTHO COIL DPR KIT 50
106
ORTHO EVRA DIS WEEK
75
ORTHO FLAT DPR KIT 55
106
ORTHO FLAT DPR KIT 60
106
ORTHO FLAT DPR KIT 65
106
ORTHO FLAT DPR KIT 70
106
ORTHO FLAT DPR KIT 75
106
ORTHO FLAT DPR KIT 80
106
ORTHO FLAT DPR KIT 85
106
ORTHO FLAT DPR KIT 90
106
ORTHO FLAT DPR KIT 95
106
ORTHO FLEX DPR 65MM
106
ORTHO FLEX DPR 70MM
106
ORTHO FLEX DPR 75MM
106
ORTHO FLEX DPR 80MM
106
ORTHO TRI- TAB CYCLN LO
75
ortho-est tab 0.625
97
ortho-est tab 1.25
97
ORTHOCLONE INJ OKT3
64
oscimin sr tab 0.375mg
128
oscimin sub 0.125mg
128
oscimin tab 0.125mg
128
oscion clnsr lot 6%
81
oscion clnsr lot 9%
81
OSMOPREP TAB 1.5GM
105
OVCON 50 TAB 28
75
oxacillin sodium for inj 1 gm
121
oxacillin sodium for inj 10 gm
121
oxacillin sodium for inj 2 gm
121
oxaliplatin for iv inj 100 mg
49
oxaliplatin for iv inj 50 mg
49
oxaliplatin iv soln 100 mg/20ml
49
oxaliplatin iv soln 50 mg/10ml
49
oxandrolone tab 10 mg
13
oxandrolone tab 2.5 mg
13
oxaprozin tab 600 mg
6
oxazepam cap 10 mg
19
oxazepam cap 15 mg
19
oxazepam cap 30 mg
19
oxcarbazepine susp 300 mg/5ml (60
mg/ml)
26
oxcarbazepine tab 150 mg
26
oxcarbazepine tab 300 mg
26
oxcarbazepine tab 600 mg
26
OXECTA TAB 5MG
11
OXECTA TAB 7.5MG
11
OXISTAT CRE 1%
83
OXISTAT LOT 1%
83
OXSORALEN-UL CAP 10MG
84
oxybutynin chloride syrup 5 mg/5ml
131
oxybutynin chloride tab 5 mg
131
oxybutynin chloride tab sr 24hr 10 mg 131
oxybutynin chloride tab sr 24hr 15 mg 131
oxybutynin chloride tab sr 24hr 5 mg 131
oxycodone hcl cap 5 mg
11
oxycodone hcl conc 100 mg/5ml (20
mg/ml)
11
oxycodone hcl soln 5 mg/5ml
11
oxycodone hcl tab 10 mg
11
oxycodone hcl tab 15 mg
11
oxycodone hcl tab 20 mg
11
oxycodone hcl tab 30 mg
11
oxycodone hcl tab 5 mg
11
oxycodone w/ acetaminophen tab 10-325
mg
12
164
oxycodone w/ acetaminophen tab 2.5-325
mg
12
oxycodone w/ acetaminophen tab 5-325
mg
12
oxycodone w/ acetaminophen tab 7.5-325
mg
12
oxycodone-aspirin tab 4.8355-325 mg 12
oxycodone-ibuprofen tab 5-400 mg
12
OXYCONTIN TAB 10MG CR
11
OXYCONTIN TAB 15MG CR
11
OXYCONTIN TAB 20MG CR
11
OXYCONTIN TAB 30MG CR
11
OXYCONTIN TAB 40MG CR
11
OXYCONTIN TAB 60MG CR
11
OXYCONTIN TAB 80MG CR
11
oxymorphone hcl tab 10 mg
11
oxymorphone hcl tab 5 mg
11
oxymorphone hcl tab sr 12hr 10 mg
11
oxymorphone hcl tab sr 12hr 15 mg
11
oxymorphone hcl tab sr 12hr 20 mg
11
oxymorphone hcl tab sr 12hr 30 mg
11
oxymorphone hcl tab sr 12hr 40 mg
11
oxymorphone hcl tab sr 12hr 5 mg
11
oxymorphone hcl tab sr 12hr 7.5 mg
11
OXYTROL DIS 3.9MG/24
131
P
pacerone tab 100mg
20
pacerone tab 200mg
20
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml)
55
paclitaxel iv conc 150 mg/25ml (6
mg/ml)
55
paclitaxel iv conc 30 mg/5ml (6 mg/ml) 54
paclitaxel iv conc 300 mg/50ml (6
mg/ml)
55
PACNEX HP PAD 7%
81
PACNEX LP PAD 4.25%
81
pacnex wash liq 7%
81
pamidronate disodium for inj 30 mg
90
pamidronate disodium for inj 90 mg
90
pamidronate disodium iv soln 3 mg/ml 90
pamidronate disodium iv soln 9 mg/ml 90
PAMIDRONATE INJ 6MG/ML
90
pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit
88
PANRETIN GEL 0.1%
83
pantoprazole sodium ec tab 20 mg (base
equiv)
130
pantoprazole sodium ec tab 40 mg (base
equiv)
130
parcaine sol 0.5% op
116
paricalcitol cap 1 mcg
92
paricalcitol cap 2 mcg
92
paricalcitol cap 4 mcg
92
paromomycin sulfate cap 250 mg
4
paroxetine hcl tab 10 mg
29
paroxetine hcl tab 20 mg
29
paroxetine hcl tab 30 mg
29
paroxetine hcl tab 40 mg
29
paroxetine hcl tab sr 24hr 12.5 mg
29
paroxetine hcl tab sr 24hr 25 mg
29
paroxetine hcl tab sr 24hr 37.5 mg
29
PASER GRA 4GM
48
PATADAY SOL 0.2%
117
PATANASE SPR 0.6%
113
PATANOL SOL 0.1% OP
117
PAXIL SUS 10MG/5ML
29
PCE TAB 333MG EC
106
PCE TAB 500MG EC
106
pedi-dri pow 100000
83
pedia d-vite dro 400unit
134
PEDIADERM HC KIT
86
PEDIADERM TA KIT
86
PEDIARIX INJ 0.5ML
127
PEDVAX HIB INJ
132
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm
104
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 240 gm
104
peg 3350-kcl-sod bicarb-nacl for soln 420
gm
104
PEG-INTRON KIT 120 RP
63
PEG-INTRON KIT 120MCG
63
PEG-INTRON KIT 150 RP
63
PEG-INTRON KIT 150MCG
63
PEG-INTRON KIT 50MCG
62
PEG-INTRON KIT 50MCG RP
62
PEG-INTRON KIT 80MCG
62
PEG-INTRON KIT 80MCG RP
63
PEGANONE TAB 250MG
27
PEGASYS INJ
63
PEGASYS INJ 180MCG/M
63
PEGASYS INJ PROCLICK
63
PEGASYS KIT
63
PEN G PROC INJ 600000
119
PENICILL GK/ INJ DEX 1MU
119
PENICILL GK/ INJ DEX 2MU
120
PENICILL GK/ INJ DEX 3MU
120
penicillin g potassium for inj 20000000
unit
120
penicillin g potassium for inj 5000000
unit
120
penicillin g sodium for inj 5000000 unit120
penicillin v potassium for soln 125
mg/5ml
120
penicillin v potassium for soln 250
mg/5ml
120
penicillin v potassium tab 250 mg
120
penicillin v potassium tab 500 mg
120
PENTACEL INJ
127
PENTAM 300 INJ 300MG
14
pentopak tab 400mg cr
101
pentostatin for inj 10 mg
54
pentoxifylline tab cr 400 mg
101
PERFOROMIST NEB 20MCG
22
perindopril erbumine tab 2 mg
43
perindopril erbumine tab 4 mg
43
perindopril erbumine tab 8 mg
43
periogard sol 0.12%
111
165
permethrin cream 5%
87
perphenazine tab 16 mg
59
perphenazine tab 2 mg
59
perphenazine tab 4 mg
59
perphenazine tab 8 mg
59
PEXEVA TAB 10MG
29
PEXEVA TAB 20MG
29
PEXEVA TAB 30MG
29
PEXEVA TAB 40MG
29
pfizerpen-g inj 20mu
120
phenadoz sup 12.5mg
40
phenadoz sup 25mg
40
phenazopyridine hcl tab 100 mg
100
phenazopyridine hcl tab 200 mg
100
phenelzine sulfate tab 15 mg
28
phenobarbital elixir 20 mg/5ml
103
phenobarbital tab 100 mg
103
phenobarbital tab 15 mg
103
phenobarbital tab 16.2 mg
103
phenobarbital tab 30 mg
103
phenobarbital tab 32.4 mg
103
phenobarbital tab 60 mg
103
phenobarbital tab 64.8 mg
103
phenobarbital tab 97.2 mg
103
phenylephrine hcl ophth soln 10%
116
phenylephrine hcl ophth soln 2.5%
116
phenytoin chew tab 50 mg
27
phenytoin sodium extended cap 100 mg 27
phenytoin sodium extended cap 200 mg 27
phenytoin sodium extended cap 300 mg 27
phenytoin sodium inj 50 mg/ml
27
phenytoin susp 125 mg/5ml
27
PHISOHEX LIQ 3%
60
PHLUORIVIT + DRO FE
111
phluorivit dro
111
PHOSLYRA SOL
100
PHOSPHOLINE SOL 0.125%OP
115
PHOTOFRIN INJ 75MG
54
physiolyte sol
65
physiosol sol irrigat
65
PICATO GEL 0.015%
83
PICATO GEL 0.05%
83
pilocarpine hcl tab 5 mg
111
pilocarpine hcl tab 7.5 mg
111
PILOPINE HS GEL 4% OP
115
pindolol tab 10 mg
66
pindolol tab 5 mg
66
pioglitazone hcl tab 15 mg (base equiv) 35
pioglitazone hcl tab 30 mg (base equiv) 35
pioglitazone hcl tab 45 mg (base equiv) 35
pioglitazone hcl-glimepiride tab 30-2 mg34
pioglitazone hcl-glimepiride tab 30-4 mg34
pioglitazone hcl-metformin hcl tab 15-500
mg
34
pioglitazone hcl-metformin hcl tab 15-850
mg
34
PIPERACILLIN INJ 2GM
119
PIPERACILLIN INJ 40GM
119
PIPERACILLIN INJ 4GM
119
piperacillin sodium-tazobactam sodium for
inj 2-0.25 gm
120
piperacillin sodium-tazobactam sodium for
inj 3-0.375 gm
120
piperacillin sodium-tazobactam sodium for
inj 36-4.5 gm
121
piperacillin sodium-tazobactam sodium for
inj 4-0.5 gm
121
piroxicam cap 10 mg
6
piroxicam cap 20 mg
6
PLASMA-LYTE INJ -148
108
PLASMA-LYTE INJ -A
108
PLASMA-LYTE INJ 56
108
PNEUMOVAX 23 INJ 25/0.5
132
podofilox soln 0.5%
87
poly-dex oin 0.1% op
116
POLY-VI-FLOR CHW 0.25MG
111
POLY-VI-FLOR CHW 0.5MG
111
POLY-VI-FLOR CHW 1MG
111
POLY-VIT/FE DRO /FL 0.25
111
poly-vit/fe dro /fl 0.5
111
poly-vit/fl dro 0.25mg
111
polycin oin op
115
polyethylene glycol 3350 oral packet 105
polymyxin b sulfate for inj 500000 unit 16
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1%
115
polyvit/fl dro 0.5mg/ml
111
POMALYST CAP 1MG
53
POMALYST CAP 2MG
53
POMALYST CAP 3MG
53
POMALYST CAP 4MG
53
portia-28 tab
75
potassium chloride cap cr 10 meq
110
potassium chloride cap cr 8 meq
110
potassium chloride inj 10 meq/100 ml 110
potassium chloride inj 10 meq/50 ml 110
potassium chloride inj 2 meq/ml
110
potassium chloride inj 20 meq/100 ml 110
potassium chloride inj 20 meq/50 ml 110
potassium chloride inj 30 meq/100 ml 110
potassium chloride inj 40 meq/100 ml 110
potassium chloride microencapsulated crys
cr tab 10 meq
110
potassium chloride microencapsulated crys
cr tab 20 meq
110
potassium chloride oral liq 10% (20
meq/15ml)
110
potassium chloride oral liq 20% (40
meq/15ml)
110
potassium chloride tab cr 10 meq
110
POTASSIUM CHLORIDE TAB CR 20 MEQ
(1500 MG)
110
potassium chloride tab cr 8 meq (600
mg)
110
potassium citrate tab cr 10 meq (1080
mg)
100
potassium citrate tab cr 15 meq (1620
mg)
100
potassium citrate tab cr 5 meq (540
mg)
100
POTIGA TAB 200MG
26
166
POTIGA TAB 300MG
26
POTIGA TAB 400MG
26
POTIGA TAB 50MG
26
pr benzoyl liq 7% wash
81
PRADAXA CAP 150MG
24
PRADAXA CAP 75MG
24
pramipexole dihydrochloride tab 0.125
mg
56
pramipexole dihydrochloride tab 0.25
mg
56
pramipexole dihydrochloride tab 0.5 mg 56
pramipexole dihydrochloride tab 0.75
mg
56
pramipexole dihydrochloride tab 1 mg 56
pramipexole dihydrochloride tab 1.5 mg 56
pramox gel 1%
87
pravastatin sodium tab 10 mg
42
pravastatin sodium tab 20 mg
42
pravastatin sodium tab 40 mg
42
pravastatin sodium tab 80 mg
42
prazosin hcl cap 1 mg
45
prazosin hcl cap 2 mg
45
prazosin hcl cap 5 mg
45
PRED MILD SUS 0.12% OP
116
PRED SOD PHO SOL 1% OP
116
prednicarbate cream 0.1%
86
prednicarbate oint 0.1%
86
prednisolone acetate ophth susp 1% 116
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
77
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
77
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq)
77
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
77
PREDNISONE CON 5MG/ML
77
prednisone oral soln 5 mg/5ml
77
prednisone tab 1 mg
77
prednisone tab 10 mg
77
prednisone tab 10 mg dose pack
77
prednisone tab 2.5 mg
77
prednisone tab 20 mg
77
prednisone tab 5 mg
77
prednisone tab 5 mg dose pack
77
prednisone tab 50 mg
77
pregnyl inj 10000unt
90
PREMARIN INJ 25MG
97
PREMARIN TAB 0.3MG
97
PREMARIN TAB 0.45MG
97
PREMARIN TAB 0.625MG
97
PREMARIN TAB 0.9MG
97
PREMARIN TAB 1.25MG
97
PREMARIN VAG CRE 0.625MG
134
PRENTIF MIS 22MM
106
PRENTIF MIS 25MM
106
PRENTIF MIS 28MM
106
PRENTIF MIS 31MM
106
PRENTIF MIS FITTING
106
PREPOPIK PAK
104
prevalite pow 4gm
previfem tab
PREVNAR 13 INJ
PREZISTA SUS 100MG/ML
PREZISTA TAB 150MG
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
PRIFTIN TAB 150MG
PRIMAQUINE TAB 26.3MG
primidone tab 250 mg
primidone tab 50 mg
PRIMLEV TAB 10-300MG
PRIMLEV TAB 5-300MG
PRIMLEV TAB 7.5-300
PRIMSOL SOL 50MG/5ML
PRISTIQ TAB 100MG
PRISTIQ TAB 50MG
PRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 40GRAMS
PRIVIGEN INJ 5 GRAMS
PROAIR HFA AER
probenecid tab 500 mg
procainamide hcl inj 100 mg/ml
PROCAINAMIDE INJ 500MG/ML
prochlorperazine edisylate inj 5 mg/ml
prochlorperazine maleate tab 10 mg
prochlorperazine maleate tab 5 mg
prochlorperazine suppos 25 mg
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
procto-pak cre 1%
proctocream cre -hc 2.5%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%
progesterone micronized cap 100 mg
progesterone micronized cap 200 mg
PROGLYCEM SUS 50MG/ML
PROGRAF INJ 5MG/ML
PROLASTIN INJ 1000MG
PROLASTIN INJ 500MG
PROLASTIN-C INJ 1000MG
PROLIA SOL 60MG/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
prometh vc syp 6.25-5/5
prometh vc/ syp codeine
promethazine hcl inj 25 mg/ml
promethazine hcl inj 50 mg/ml
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
41
75
132
61
61
61
61
61
61
48
47
26
26
13
12
12
14
30
30
119
119
119
119
22
101
19
19
59
59
59
59
102
102
102
102
102
102
14
14
14
14
121
121
34
64
124
124
124
90
102
102
103
103
78
78
40
40
40
41
41
167
promethazine hcl tab 12.5 mg
41
promethazine hcl tab 25 mg
41
promethazine hcl tab 50 mg
41
promethazine w/ codeine syrup 6.25-10
mg/5ml
78
promethazine-dm syrup 6.25-15
mg/5ml
78
promethegan sup 12.5mg
41
promethegan sup 25mg
41
promethegan sup 50mg
41
propafenone hcl cap sr 12hr 225 mg
19
propafenone hcl cap sr 12hr 325 mg
19
propafenone hcl cap sr 12hr 425 mg
19
propafenone hcl tab 150 mg
19
propafenone hcl tab 225 mg
19
propafenone hcl tab 300 mg
19
proparacaine hcl ophth soln 0.5%
116
propranolol & hydrochlorothiazide tab 4025 mg
46
propranolol & hydrochlorothiazide tab 8025 mg
46
propranolol hcl cap sr 24hr 120 mg
66
propranolol hcl cap sr 24hr 160 mg
66
propranolol hcl cap sr 24hr 60 mg
66
propranolol hcl cap sr 24hr 80 mg
66
propranolol hcl inj 1 mg/ml
66
propranolol hcl oral soln 20 mg/5ml
66
propranolol hcl oral soln 40 mg/5ml
66
propranolol hcl tab 10 mg
66
propranolol hcl tab 20 mg
66
propranolol hcl tab 40 mg
66
propranolol hcl tab 60 mg
66
propranolol hcl tab 80 mg
66
propylthiouracil tab 50 mg
125
PROQUAD INJ
133
PROTONIX PAK
130
PROTOPIC OIN 0.03%
87
PROTOPIC OIN 0.1%
87
protriptyline hcl tab 10 mg
33
protriptyline hcl tab 5 mg
33
prudoxin cre 5%
83
PULMICORT INH 180MCG
21
PULMICORT INH 90MCG
21
PULMICORT SUS 1MG/2ML
21
pyrazinamide tab 500 mg
48
pyridostigmine bromide tab 60 mg
47
Q
QUADRAMET INJ
QUARTETTE TAB
quasense tab
quetiapine fumarate tab
quetiapine fumarate tab
quetiapine fumarate tab
quetiapine fumarate tab
quetiapine fumarate tab
quetiapine fumarate tab
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
100 mg
200 mg
25 mg
300 mg
400 mg
50 mg
53
75
75
59
59
59
59
59
59
43
43
43
quinapril hcl tab 5 mg
43
quinapril-hydrochlorothiazide tab 10-12.5
mg
46
quinapril-hydrochlorothiazide tab 20-12.5
mg
46
quinapril-hydrochlorothiazide tab 20-25
mg
46
quinidine gluconate tab cr 324 mg
19
quinidine sulfate tab cr 300 mg
19
quinine sulfate cap 324 mg
47
quinine sulfate tab 260 mg
47
QVAR AER 40MCG
21
QVAR AER 80MCG
21
R
rabeprazole sodium ec tab 20 mg
ramipril cap 1.25 mg
ramipril cap 10 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
RANEXA TAB 1000MG
RANEXA TAB 500MG
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl inj 1000 mg/40ml (25
mg/ml)
ranitidine hcl inj 150 mg/6ml (25
mg/ml)
ranitidine hcl inj 50 mg/2ml (25
mg/ml)
ranitidine hcl syrup 15 mg/ml (75
mg/5ml)
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
RAPAMUNE SOL 1MG/ML
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
REBETOL SOL 40MG/ML
REBIF INJ 22/0.5
REBIF INJ 44/0.5
REBIF TITRTN SOL PACK
reclipsen tab
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA-HB INJ 40MCG/ML
RECTIV OIN 0.4%
REGONOL INJ 5MG/ML
REGRANEX GEL 0.01%
RELENZA MIS DISKHALE
RELISTOR INJ 12/0.6ML
RELISTOR INJ 8/0.4ML
RELPAX TAB 20MG
RELPAX TAB 40MG
REMICADE INJ 100MG
REMODULIN INJ 10MG/ML
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
130
43
44
43
43
16
16
128
128
128
128
128
128
128
129
100
100
64
64
64
63
123
123
123
75
133
133
133
14
47
87
63
99
99
107
107
99
70
70
70
70
168
RENVELA PAK 0.8GM
100
RENVELA PAK 2.4GM
100
RENVELA TAB 800MG
100
repaglinide tab 0.5 mg
36
repaglinide tab 1 mg
36
repaglinide tab 2 mg
36
RESCRIPTOR TAB 100 MG
61
RESCRIPTOR TAB 200MG
61
RESTASIS EMU 0.05%
116
RETROVIR INJ 10MG/ML
61
REVATIO INJ
70
REVLIMID CAP 10MG
64
REVLIMID CAP 15MG
64
REVLIMID CAP 2.5MG
64
REVLIMID CAP 20MG
64
REVLIMID CAP 25MG
64
REVLIMID CAP 5MG
64
REYATAZ CAP 100MG
61
REYATAZ CAP 150MG
61
REYATAZ CAP 200MG
61
REYATAZ CAP 300MG
61
RHEUMATREX TAB 2.5MG
5
ribasphere cap 200mg
63
ribasphere tab 200mg
63
ribasphere tab 400mg
63
ribasphere tab 600mg
63
ribavirin cap 200 mg
63
ribavirin tab 200 mg
63
rifampin cap 150 mg
48
rifampin cap 300 mg
48
rifampin for inj 600 mg
48
RIFATER TAB
48
riluzole tab 50 mg
114
rimantadine hydrochloride tab 100 mg 63
RISPERDAL INJ 12.5MG
58
RISPERDAL INJ 25MG
58
RISPERDAL INJ 37.5MG
58
RISPERDAL INJ 50MG
58
risperidone orally disintegrating tab 0.25
mg
58
risperidone orally disintegrating tab 0.5
mg
58
risperidone orally disintegrating tab 1
mg
58
risperidone orally disintegrating tab 2
mg
58
risperidone orally disintegrating tab 3
mg
58
risperidone orally disintegrating tab 4
mg
58
risperidone soln 1 mg/ml
58
risperidone tab 0.25 mg
58
risperidone tab 0.5 mg
58
risperidone tab 1 mg
58
risperidone tab 2 mg
58
risperidone tab 3 mg
58
risperidone tab 4 mg
58
RITALIN LA CAP 10MG
4
RITUXAN INJ 100MG
50
rivastigmine tartrate cap 1.5 mg
122
rivastigmine tartrate cap 3 mg
122
rivastigmine tartrate cap 4.5 mg
122
rivastigmine tartrate cap 6 mg
122
rizatriptan benzoate orally disintegrating
tab 10 mg
107
rizatriptan benzoate orally disintegrating
tab 5 mg
107
rizatriptan benzoate tab 10 mg
108
rizatriptan benzoate tab 5 mg
108
romycin oin op
115
ropinirole hydrochloride tab 0.25 mg
56
ropinirole hydrochloride tab 0.5 mg
56
ropinirole hydrochloride tab 1 mg
56
ropinirole hydrochloride tab 2 mg
56
ropinirole hydrochloride tab 3 mg
56
ropinirole hydrochloride tab 4 mg
56
ropinirole hydrochloride tab 5 mg
56
rosadan cre 0.75%
87
ROTARIX SUS
133
ROTATEQ SOL
133
ROXICET SOL 5-325/5
13
roxicet tab 5-325mg
13
ROZEREM TAB 8MG
104
S
SABRIL POW 500MG
SABRIL TAB 500MG
SAFYRAL TAB
SAIZEN INJ 5MG
SAIZEN INJ 8.8MG
SAMSCA TAB 15MG
SAMSCA TAB 30MG
SANCUSO DIS 3.1MG
SANDIMMUNE SOL 100MG/ML
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SANTYL OIN 250/GM
SAPHRIS SUB 10MG
SAPHRIS SUB 5MG
SAVELLA MIS TITR PAK
SAVELLA TAB 100MG
SAVELLA TAB 12.5MG
SAVELLA TAB 25MG
SAVELLA TAB 50MG
scalacort lot 2%
se bpo cloth mis 3%
se bpo cloth mis 6%
se bpo cloth mis 9%
se bpo wash liq 7%
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
selenium sulfide lotion 2.5%
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
SEREVENT DIS AER 50MCG
SEROQUEL XR TAB 150MG
27
27
75
91
91
93
93
38
65
93
93
93
86
59
59
122
122
122
122
122
86
81
81
81
81
57
57
84
61
61
92
92
92
22
59
169
SEROQUEL XR TAB 200MG
59
SEROQUEL XR TAB 300MG
59
SEROQUEL XR TAB 400MG
59
SEROQUEL XR TAB 50MG
59
SEROSTIM INJ 4MG
91
SEROSTIM INJ 5MG
91
SEROSTIM INJ 6MG
91
sertraline hcl oral conc 20 mg/ml
29
sertraline hcl tab 100 mg
29
sertraline hcl tab 25 mg
29
sertraline hcl tab 50 mg
29
SHUR-SEAL GEL 2%
133
sildenafil citrate tab 20 mg
70
silver sulfadiazine cream 1%
84
SIMPONI ARIA SOL 50MG/4ML
4
SIMPONI INJ 100MG/ML
5
SIMPONI INJ 50MG
4
SIMULECT INJ 10MG
65
SIMULECT INJ 20MG
65
simvastatin tab 10 mg
42
simvastatin tab 20 mg
42
simvastatin tab 40 mg
43
simvastatin tab 5 mg
42
simvastatin tab 80 mg
43
sirolimus tab 0.5 mg
65
SKELID TAB 200MG
90
SKLICE LOT 0.5%
87
SKYLA IUD 13.5MG
76
sm nicotine dis 14mg/24h
124
sm nicotine dis 21mg
124
sm nicotine dis 7mg/24hr
124
sm vitamin d tab 400unit
134
SOD EDECRIN INJ 50MG
89
sodiphluor dro 1.1mg/ml
109
sodium chloride inj 0.45%
110
sodium chloride inj 0.9%
110
sodium chloride inj 2.5 meq/ml
(14.6%)
110
sodium chloride inj 3%
110
sodium chloride inj 4 meq/ml (23.4%) 110
sodium chloride inj 5%
110
sodium chloride irrigation soln 0.9%
100
sodium chloride iv soln 0.9%
110
sodium chloride soln nebu 0.9%
78
sodium chloride soln nebu 10%
78
sodium chloride soln nebu 3%
78
sodium chloride soln nebu 7%
78
sodium fluoride chew tab 0.25 mg f (from
0.55 mg naf)
109
sodium fluoride chew tab 0.5 mg f (from
1.1 mg naf)
109
sodium fluoride chew tab 1 mg f (from 2.2
mg naf)
109
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
109
sodium fluoride soln 0.5 mg/ml f (from 1.1
mg/ml naf)
109
sodium fluoride tab 0.5 mg f (from 1.1 mg
naf)
109
sodium fluoride tab 1 mg f (from 2.2 mg
naf)
109
sodium phenylbutyrate oral powder 3
gm/teaspoonful
92
sodium polystyrene sulfonate oral susp 15
gm/60ml
65
sodium polystyrene sulfonate rectal susp
30 gm/120ml
65
solia tab
75
SOLU-CORTEF INJ 1000MG
77
SOLU-CORTEF INJ 250MG
77
SOLU-CORTEF INJ 500MG
77
SOLU-MEDROL INJ 2GM
77
SOMATULINE INJ 120/.5ML
93
SOMATULINE INJ 60/0.2ML
93
SOMATULINE INJ 90/0.3ML
93
SOMAVERT INJ 10MG
90
SOMAVERT INJ 15MG
90
SOMAVERT INJ 20MG
90
sorine tab 120mg
66
sorine tab 160mg
66
sorine tab 240mg
66
sorine tab 80mg
66
sotalol hcl (afib/afl) tab 120 mg
66
sotalol hcl (afib/afl) tab 160 mg
66
sotalol hcl (afib/afl) tab 80 mg
66
SOTALOL HCL INJ 150/10ML
66
sotalol hcl tab 120 mg
67
sotalol hcl tab 160 mg
67
sotalol hcl tab 240 mg
67
sotalol hcl tab 80 mg
67
sotret cap 10mg
81
sotret cap 20mg
81
sotret cap 30mg
81
SOVALDI TAB 400MG
63
spinosad susp 0.9%
87
SPIRIVA CAP HANDIHLR
20
spironolactone & hydrochlorothiazide tab
25-25 mg
88
spironolactone tab 100 mg
89
spironolactone tab 25 mg
89
spironolactone tab 50 mg
89
SPORANOX SOL 10MG/ML
40
sprintec 28 tab 28 day
75
SPRYCEL TAB 100MG
53
SPRYCEL TAB 140MG
53
SPRYCEL TAB 20MG
52
SPRYCEL TAB 50MG
52
SPRYCEL TAB 70MG
52
SPRYCEL TAB 80MG
52
sronyx tab
75
ssd cre 1%
84
stavudine cap 15 mg
62
stavudine cap 20 mg
62
stavudine cap 30 mg
62
stavudine cap 40 mg
62
stavudine for oral soln 1 mg/ml
62
STAVZOR CAP 125MG
27
STAVZOR CAP 250MG
27
STAVZOR CAP 500MG
27
STELARA INJ 45MG/0.5
84
170
STELARA INJ 90MG/ML
84
STIVARGA TAB 40MG
53
STRATTERA CAP 100MG
2
STRATTERA CAP 10MG
2
STRATTERA CAP 18MG
2
STRATTERA CAP 25MG
2
STRATTERA CAP 40MG
2
STRATTERA CAP 60MG
2
STRATTERA CAP 80MG
2
streptomycin sulfate for inj 1 gm
4
STRIBILD TAB
62
STROMECTOL TAB 3MG
14
SUBOXONE MIS 12-3MG
13
SUBOXONE MIS 2-0.5MG
13
SUBOXONE MIS 4-1MG
13
SUBOXONE MIS 8-2MG
13
SUBSYS SPR 100MCG
11
SUBSYS SPR 1200MCG
12
SUBSYS SPR 1600MCG
12
SUBSYS SPR 200MCG
11
SUBSYS SPR 400MCG
11
SUBSYS SPR 600MCG
11
SUBSYS SPR 800MCG
12
SUCRAID SOL 8500/ML
88
sucralfate tab 1 gm
129
sudatuss-2 sol
78
sudatuss-sf sol
78
sulfacetamide sodium lotion 10% (acne)81
sulfacetamide sodium ophth soln 10% 115
sulfacetamide sodium w/ sulfur cleansing
cloth 10-5%
81
sulfacetamide sodium w/ sulfur cleansing
pad 10-4%
81
sulfacetamide sodium w/ sulfur cream 105%
81
sulfacetamide sodium w/ sulfur lotion 105%
81
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
116
SULFADIAZINE TAB 500MG
124
sulfamethoxazole-trimethoprim iv soln
400-80 mg/5ml
15
sulfamethoxazole-trimethoprim susp 20040 mg/5ml
15
sulfamethoxazole-trimethoprim tab 40080 mg
15
sulfamethoxazole-trimethoprim tab 800160 mg
15
SULFAMYLON CRE 85MG/GM
84
sulfasalazine tab 500 mg
99
sulfasalazine tab delayed release 500
mg
99
sulfazine tab 500mg
99
sulindac tab 150 mg
6
sulindac tab 200 mg
6
sumatriptan nasal spray 20 mg/act
108
sumatriptan nasal spray 5 mg/act
108
sumatriptan succinate inj 6 mg/0.5ml 108
sumatriptan succinate solution autoinjector 4 mg/0.5ml
108
sumatriptan succinate solution auto-
injector 6 mg/0.5ml
sumatriptan succinate tab 100 mg
sumatriptan succinate tab 25 mg
sumatriptan succinate tab 50 mg
suphera cre 10-5%
SUPRAX CAP 400MG
SUPRAX CHW 100MG
SUPRAX CHW 200MG
SUPRAX SUS 100/5ML
SUPRAX SUS 200/5ML
SUPRAX SUS 500/5ML
SUPRAX TAB 400MG
SUPREP BOWEL SOL PREP
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA CAP 50MG
SUSTIVA TAB 600MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
syeda tab 3-0.03mg
symax fastab tab 0.125mg
symax-sl sub 0.125mg
SYMBICORT AER 160-4.5
SYMBICORT AER 80-4.5
SYMLIN INJ 600MCG
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
SYNAREL SOL 2MG/ML
SYNERA DIS 70-70MG
SYNRIBO INJ 3.5MG
SYPRINE CAP 250MG
T
TABLOID TAB 40MG
TACLONEX OIN
TACLONEX SUS
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TALWIN INJ 30MG/ML
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 12MG/ML
TAMIFLU SUS 6MG/ML
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
tamsulosin hcl cap 0.4 mg
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
108
108
108
108
81
72
72
72
72
72
72
72
104
33
33
33
62
62
62
53
53
53
75
128
128
22
22
33
33
33
92
87
54
64
50
86
86
65
65
65
53
53
13
63
63
63
63
63
51
51
100
53
53
53
54
83
171
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TASMAR TAB 100MG
TAXOTERE INJ 20/0.5ML
TAXOTERE INJ 80MG/2ML
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
taztia xt cap 120mg/24
taztia xt cap 180mg/24
taztia xt cap 240mg/24
taztia xt cap 300mg/24
taztia xt cap 360mg/24
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
TEFLARO INJ 400MG
TEFLARO INJ 600MG
TEGRETOL-XR TAB 100MG
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
telmisartan tab 20 mg
telmisartan tab 40 mg
telmisartan tab 80 mg
temazepam cap 15 mg
temazepam cap 22.5 mg
temazepam cap 30 mg
temazepam cap 7.5 mg
TEMODAR INJ 100MG
temozolomide cap 100 mg
temozolomide cap 140 mg
temozolomide cap 180 mg
temozolomide cap 20 mg
temozolomide cap 250 mg
temozolomide cap 5 mg
TENIVAC INJ 5-2LF
terazosin hcl cap 1 mg
terazosin hcl cap 10 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
terbinafine hcl tab 250 mg
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
terconazole vaginal suppos 80 mg
testosterone cypionate im in oil 100
mg/ml
testosterone cypionate im in oil 200
mg/ml
testosterone enanthate im in oil 200
mg/ml
TET/DIP TOX INJ 2-2 LF
TETANUS TOX INJ 5LF ADS
tetracycline hcl cap 250 mg
tetracycline hcl cap 500 mg
53
53
55
55
55
72
72
72
84
84
84
84
69
69
69
69
69
123
123
73
73
26
47
47
44
44
44
104
104
104
104
49
49
49
49
49
49
49
127
45
45
45
45
39
22
22
22
133
133
133
13
14
14
127
127
125
125
TEV-TROPIN INJ 5MG
91
TEVETEN TAB 400MG
44
TEXACORT SOL 2.5%
86
tgq 50pse/3 syp brm/30dm
78
THALITONE TAB 15MG
89
THALOMID CAP 100MG
64
THALOMID CAP 150MG
64
THALOMID CAP 200MG
64
THALOMID CAP 50MG
64
THEO-24 CAP 100MG CR
22
THEO-24 CAP 200MG CR
22
THEO-24 CAP 300MG CR
22
THEO-24 CAP 400MG ER
22
theochron tab 100mg cr
23
theochron tab 200mg cr
23
theochron tab 300mg cr
23
theophylline soln 80 mg/15ml
23
theophylline tab sr 12hr 100 mg
23
theophylline tab sr 12hr 200 mg
23
theophylline tab sr 12hr 300 mg
23
theophylline tab sr 12hr 450 mg
23
theophylline tab sr 24hr 400 mg
23
theophylline tab sr 24hr 600 mg
23
THERACYS INJ
54
thermazene cre 1%
84
thioridazine hcl tab 10 mg
59
thioridazine hcl tab 100 mg
60
thioridazine hcl tab 25 mg
59
thioridazine hcl tab 50 mg
60
THIOTEPA INJ 15MG
49
thiothixene cap 1 mg
60
thiothixene cap 10 mg
60
thiothixene cap 2 mg
60
thiothixene cap 5 mg
60
thrive gum 4mg mint
124
THYMOGLOBULN INJ 25MG
65
THYROLAR-1 TAB 60MG
126
THYROLAR-1/2 TAB 30MG
126
THYROLAR-1/4 TAB 15MG
126
THYROLAR-2 TAB 120MG
126
THYROLAR-3 TAB 180MG
126
tiagabine hcl tab 2 mg
27
tiagabine hcl tab 4 mg
27
TICE BCG INJ
54
ticlopidine hcl tab 250 mg
101
TIKOSYN CAP 125MCG
20
TIKOSYN CAP 250MCG
20
TIKOSYN CAP 500MCG
20
tilia fe tab
75
TIMENTIN INJ 3.1GM
121
timolol maleate ophth gel forming soln
0.25%
114
timolol maleate ophth gel forming soln
0.5%
114
timolol maleate ophth soln 0.25%
114
timolol maleate ophth soln 0.5%
114
timolol maleate tab 10 mg
67
timolol maleate tab 20 mg
67
timolol maleate tab 5 mg
67
TIMOPTIC OCU SOL 0.25% OP
114
172
TIMOPTIC OCU SOL 0.5% OP
114
tinidazole tab 250 mg
14
tinidazole tab 500 mg
14
tis-u-sol sol
65
tizanidine hcl cap 2 mg
113
tizanidine hcl cap 4 mg
113
tizanidine hcl cap 6 mg
113
tizanidine hcl tab 2 mg
113
tizanidine hcl tab 4 mg
113
TOBRA/NACL INJ 60/0.9
4
TOBRA/NACL INJ 80/0.9
4
TOBRADEX OIN 0.3-0.1%
116
tobramycin nebu soln 300 mg/5ml
4
tobramycin ophth soln 0.3%
115
tobramycin sulfate inj 1.2 gm/30ml (40
mg/ml)
4
tobramycin sulfate inj 10 mg/ml
4
tobramycin sulfate inj 2 gm/50ml (40
mg/ml)
4
tobramycin sulfate inj 80 mg/2ml (40
mg/ml)
4
tobramycin-dexamethasone ophth susp
0.3-0.1%
116
TOBREX OIN 0.3% OP
115
TODAY SPONGE MIS
106
tolazamide tab 250 mg
37
tolazamide tab 500 mg
37
tolbutamide tab 500 mg
37
tolmetin sodium cap 400 mg
6
tolmetin sodium tab 200 mg
6
tolmetin sodium tab 600 mg
6
tolterodine tartrate cap sr 24hr 2 mg 131
tolterodine tartrate cap sr 24hr 4 mg 131
tolterodine tartrate tab 1 mg
131
tolterodine tartrate tab 2 mg
131
topiragen tab 100mg
26
topiragen tab 200mg
26
topiragen tab 25mg
26
topiragen tab 50mg
26
topiramate sprinkle cap 15 mg
26
topiramate sprinkle cap 25 mg
26
topiramate tab 100 mg
26
topiramate tab 200 mg
26
topiramate tab 25 mg
26
topiramate tab 50 mg
26
topisulf cre 10-5%
81
toposar inj 100/5ml
55
toposar inj 20mg/ml
55
topotecan hcl for inj 4 mg
55
TOPOTECAN INJ 4MG/4ML
55
TORISEL SOL 25MG/ML
53
TORSEMIDE INJ 20MG/2ML
89
TORSEMIDE INJ 50MG/5ML
89
torsemide tab 10 mg
89
torsemide tab 100 mg
89
torsemide tab 20 mg
89
torsemide tab 5 mg
89
TOVIAZ TAB 4MG
131
TOVIAZ TAB 8MG
131
TRACLEER TAB 125MG
70
TRACLEER TAB 62.5MG
70
TRADJENTA TAB 5MG
35
tramadol hcl tab 50 mg
12
tramadol hcl tab sr 24hr 100 mg
12
tramadol hcl tab sr 24hr 200 mg
12
tramadol hcl tab sr 24hr 300 mg
12
trandolapril tab 1 mg
44
trandolapril tab 2 mg
44
trandolapril tab 4 mg
44
tranexamic acid inj 100 mg/ml
103
tranexamic acid tab 650 mg
103
TRANSDERM-SC DIS 1.5MG
38
tranylcypromine sulfate tab 10 mg
28
TRAVATAN Z DRO 0.004%
117
trazodone hcl tab 100 mg
28
trazodone hcl tab 150 mg
28
trazodone hcl tab 300 mg
28
trazodone hcl tab 50 mg
28
TRECATOR TAB 250MG
48
TRELSTAR DEP INJ 3.75MG
51
TRELSTAR LA INJ 11.25MG
51
TRELSTAR MIX INJ 22.5MG
51
TRETIN-X CRE 0.0375%
81
TRETIN-X CRE 0.075%
81
tretinoin cap 10 mg
54
tretinoin cream 0.025%
81
tretinoin cream 0.05%
81
tretinoin cream 0.1%
81
tretinoin gel 0.01%
82
tretinoin gel 0.025%
82
tretinoin microsphere gel 0.04%
82
tretinoin microsphere gel 0.1%
82
TREXALL TAB 10MG
50
TREXALL TAB 15MG
50
TREXALL TAB 5MG
50
TREXALL TAB 7.5MG
50
tri-linyah tab
75
tri-lo- tab sprintec
75
tri-previfem tab
75
tri-sprintec tab
75
tri-vit/fe dro /fl 0.25
111
tri-vit/fl dro 0.25mg
111
tri-vit/fl dro 0.5mg
111
tri-vit/fluo dro 0.25mg
111
tri-vit/fluo dro 0.5mg
111
tri-vita/fl dro 0.25mg
111
triamcinolone acetonide cream 0.025% 86
triamcinolone acetonide cream 0.1%
86
triamcinolone acetonide cream 0.5%
86
triamcinolone acetonide dental paste
0.1%
111
triamcinolone acetonide lotion 0.025% 86
triamcinolone acetonide lotion 0.1%
86
triamcinolone acetonide nasal inhal 55
mcg/act
114
triamcinolone acetonide oint 0.025%
86
triamcinolone acetonide oint 0.1%
86
triamcinolone acetonide oint 0.5%
86
triamterene & hydrochlorothiazide cap
37.5-25 mg
88
173
triamterene & hydrochlorothiazide cap 5025 mg
88
triamterene & hydrochlorothiazide tab
37.5-25 mg
88
triamterene & hydrochlorothiazide tab 7550 mg
88
TRIANEX OIN 0.05%
86
triderm cre 0.1%
86
trifluoperazine hcl tab 1 mg
60
trifluoperazine hcl tab 10 mg
60
trifluoperazine hcl tab 2 mg
60
trifluoperazine hcl tab 5 mg
60
trifluridine ophth soln 1%
115
trihexyphenidyl hcl elixir 0.4 mg/ml
55
trihexyphenidyl hcl tab 2 mg
55
trihexyphenidyl hcl tab 5 mg
55
TRIHIBIT KIT P/F
127
trilyte sol
104
trimethobenzamide hcl cap 300 mg
38
trimethobenzamide hcl inj 100 mg/ml 38
trimethoprim tab 100 mg
14
trimipramine maleate cap 100 mg
33
trimipramine maleate cap 25 mg
33
trimipramine maleate cap 50 mg
33
trinessa tab
75
TRIPEDIA SUS P/F
127
TRISENOX SOL 10MG/10M
54
trivora-28 tab
75
tropicamide ophth soln 0.5%
115
tropicamide ophth soln 1%
115
trospium chloride cap sr 24hr 60 mg 131
trospium chloride tab 20 mg
131
TRUVADA TAB 200-300
62
tussigon tab 5mg
78
TWINRIX INJ
133
TYGACIL INJ 50MG
15
TYKERB TAB 250MG
53
TYSABRI INJ 300/15ML
123
TYVASO START SOL 0.6MG/ML
70
TYZEKA TAB 600MG
63
TYZINE PED DRO 0.05%
114
TYZINE SOL 0.1%
114
U
ULESFIA LOT 5%
ULORIC TAB 40MG
ULORIC TAB 80MG
ULTRESA CAP 13800UNT
ULTRESA CAP 20700UNT
ULTRESA CAP 23000UNT
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 137mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 50mcg
87
101
101
88
88
88
126
126
126
127
127
127
127
126
127
126
unithroid tab 75mcg
unithroid tab 88mcg
univert tab 32mg
ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
UVADEX INJ 20MCG/ML
126
126
38
99
99
99
54
V
VAGIFEM TAB 10MCG
134
valacyclovir hcl tab 1 gm
63
valacyclovir hcl tab 500 mg
63
VALCYTE SOL 50MG/ML
62
VALCYTE TAB 450MG
62
valproate sodium inj 100 mg/ml
27
valproate sodium syrup 250 mg/5ml (base
equiv)
27
valproic acid cap 250 mg
27
valsartan-hydrochlorothiazide tab 16012.5 mg
46
valsartan-hydrochlorothiazide tab 160-25
mg
46
valsartan-hydrochlorothiazide tab 32012.5 mg
47
valsartan-hydrochlorothiazide tab 320-25
mg
47
valsartan-hydrochlorothiazide tab 80-12.5
mg
46
vancomycin hcl cap 125 mg
14
vancomycin hcl cap 250 mg
14
vancomycin hcl for inj 10 gm
15
vancomycin hcl for inj 1000 mg
15
vancomycin hcl for inj 500 mg
15
vancomycin hcl for inj 5000 mg
15
vandazole gel 0.75%
133
VAQTA INJ 25/0.5ML
133
VAQTA INJ 50UNT/ML
133
VARIVAX INJ
133
VCF VAGINAL AER CONTRACP
133
VCF VAGINAL MIS CONTRACP
133
velivet pak
75
VELTIN GEL
82
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)
30
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
30
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
30
venlafaxine hcl tab 100 mg
30
venlafaxine hcl tab 25 mg
30
venlafaxine hcl tab 37.5 mg
30
venlafaxine hcl tab 50 mg
30
venlafaxine hcl tab 75 mg
30
venlafaxine hcl tab sr 24hr 150 mg (base
equivalent)
30
venlafaxine hcl tab sr 24hr 225 mg (base
equivalent)
30
venlafaxine hcl tab sr 24hr 37.5 mg (base
equivalent)
30
venlafaxine hcl tab sr 24hr 75 mg (base
174
equivalent)
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
verapamil hcl cap sr 24hr 100 mg
verapamil hcl cap sr 24hr 120 mg
verapamil hcl cap sr 24hr 180 mg
verapamil hcl cap sr 24hr 200 mg
verapamil hcl cap sr 24hr 240 mg
verapamil hcl cap sr 24hr 300 mg
verapamil hcl cap sr 24hr 360 mg
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 120 mg
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab cr 120 mg
verapamil hcl tab cr 180 mg
verapamil hcl tab cr 240 mg
VERDESO AER 0.05%
VEREGEN OIN 15%
VERIPRED 20 SOL 20MG/5ML
VESICARE TAB 10MG
VESICARE TAB 5MG
vestura tab 3-0.02mg
VEXOL SUS 1% OP
VIBATIV INJ 250MG
VIBATIV INJ 750MG
VIBRAMYCIN SYP 50MG/5ML
vicodin es tab 7.5-300
vicodin hp tab 10-300mg
vicodin tab 5-300mg
VICTOZA INJ 18MG/3ML
VICTRELIS CAP 200MG
VIDEX SOL 2GM
VIDEX SOL 4GM
VIGAMOX DRO 0.5%
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
VINBLASTINE INJ 10MG
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
vinorelbine tartrate inj 10 mg/ml
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml)
VIOKACE TAB
viorele tab
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
VIRAMUNE XR TAB 400MG
VIRAZOLE INH 6GM
VIREAD POW 40MG/GM
30
70
70
69
69
69
69
69
69
69
69
69
69
69
69
69
69
86
82
77
131
131
75
116
15
15
125
13
13
13
35
63
62
62
115
28
28
28
28
26
26
26
26
26
26
55
55
55
55
55
55
88
75
62
62
62
62
63
62
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VISICOL TAB 1.5GM
VITAMIN D2 TAB 400UNIT
VITAMIN D3 CAP 400UNIT
VITAMIN D3 LIQ 1000UNIT
vitazol cre 0.75%
VIVELLE-DOT DIS 0.025MG
VIVELLE-DOT DIS 0.0375MG
VIVELLE-DOT DIS 0.05MG
VIVELLE-DOT DIS 0.075MG
VIVELLE-DOT DIS 0.1MG
VIVITROL INJ 380MG
VOLTAREN GEL 1%
voriconazole for susp 40 mg/ml
voriconazole tab 200 mg
voriconazole tab 50 mg
VOTRIENT TAB 200MG
VPRIV INJ 400UNIT
VUMON INJ 50MG/5ML
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
62
62
62
62
105
134
134
134
87
98
98
97
98
97
37
82
40
40
40
53
102
55
41
41
41
41
1
1
2
2
2
2
W
warfarin sodium tab 1 mg
warfarin sodium tab 10 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
wee care sus 15/1.25
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
wera tab 0.5/35
WIDE-SEAL DPR KIT 60
WIDE-SEAL DPR KIT 65
WIDE-SEAL DPR KIT 70
WIDE-SEAL DPR KIT 75
WIDE-SEAL DPR KIT 80
WIDE-SEAL DPR KIT 85
WIDE-SEAL DPR KIT 90
WIDE-SEAL DPR KIT 95
23
23
23
23
23
23
23
23
23
103
41
41
75
106
107
107
107
107
107
107
107
X
XALKORI CAP 200MG
XALKORI CAP 250MG
53
53
175
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XELJANZ TAB 5MG
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
XEOMIN INJ 100UNIT
XEOMIN INJ 50 UNIT
XGEVA INJ
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
XOLEGEL GEL 2%
XOPENEX HFA AER
XTANDI CAP 40MG
XYREM SOL 500MG/ML
Y
YERVOY INJ 200MG
YERVOY INJ 50MG
Z
zafirlukast tab 10 mg
zafirlukast tab 20 mg
zaleplon cap 10 mg
zaleplon cap 5 mg
ZALTRAP INJ 100/4ML
ZALTRAP INJ 200/8ML
ZAMICET SOL 10-325MG
ZANOSAR INJ 1GM
ZANTAC INJ 50/50ML
ZANTAC TAB 25MG EF
zarah tab 3-0.03mg
ZAVESCA CAP 100MG
zazole cre 0.4%
zazole cre 0.8%
zazole sup 80mg
ZELAPAR TAB 1.25MG
ZELBORAF TAB 240MG
ZEMAIRA INJ 1000MG
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
zenchent tab
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
zenzedi tab 2.5mg
zenzedi tab 7.5mg
zeosa chw
ZETIA TAB 10MG
ZIAGEN SOL 20MG/ML
ZIANA GEL
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
ZINACEF INJ 750MG
ZINACEF/H20 INJ 1.5GM PB
ZIOPTAN DRO 0.0015%
23
23
23
5
122
122
114
114
90
15
15
83
22
51
121
50
50
20
20
104
104
50
50
13
49
129
129
75
102
133
133
133
57
53
124
92
92
75
88
88
88
88
88
2
2
75
43
62
82
62
62
62
71
71
117
ziprasidone hcl cap 20 mg
57
ziprasidone hcl cap 40 mg
57
ziprasidone hcl cap 60 mg
57
ziprasidone hcl cap 80 mg
57
ZIRGAN GEL 0.15%
115
ZMAX SUS 2GM
105
ZODRYL DAC SUS 50
78
ZODRYL DAC SUS 60
78
ZODRYL DAC SUS 80
78
zoledronic acid inj conc for iv infusion 4
mg/5ml
90
zoledronic acid iv soln 5 mg/100ml
90
ZOLINZA CAP 100MG
53
zolmitriptan orally disintegrating tab 2.5
mg
108
zolmitriptan orally disintegrating tab 5
mg
108
zolmitriptan tab 2.5 mg
108
zolmitriptan tab 5 mg
108
zolpidem tartrate tab 10 mg
104
zolpidem tartrate tab 5 mg
104
zolpidem tartrate tab cr 12.5 mg
104
zolpidem tartrate tab cr 6.25 mg
104
ZOMETA INJ 4MG/100
90
ZOMIG SPR 2.5MG
108
ZOMIG SPR 5MG
108
zonisamide cap 100 mg
26
zonisamide cap 25 mg
26
zonisamide cap 50 mg
26
ZORBTIVE INJ 8.8MG
91
ZORTRESS TAB 0.25MG
65
ZORTRESS TAB 0.5MG
65
ZORTRESS TAB 0.75MG
65
ZOSTAVAX INJ
133
ZOSYN SOL 2-0.25GM
121
ZOSYN SOL 3-0.375G
121
ZOSYN SOL 4-0.50GM
121
zovia 1/35e tab
75
zovia 1/50e tab
75
ZUPLENZ MIS 4MG
38
ZUPLENZ MIS 8MG
38
ZYCLARA CRE 3.75%
87
ZYCLARA PUMP CRE 2.5%
87
ZYFLO CR TAB 600MG
20
ZYMAR DRO 0.3%
115
ZYTIGA TAB 250MG
51
ZYVOX SOL 2MG/ML
16
ZYVOX SUS 100MG/5M
16
ZYVOX TAB 600MG
16
176